[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]








        ASSESSING THE PROMISE AND PROGRESS OF THE CHOICE PROGRAM

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, MAY 13, 2015

                               __________

                           Serial No. 114-19

                               __________

       Printed for the use of the Committee on Veterans' Affairs



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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
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both printed and electronic versions of the hearing record, the process 
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unintentional errors or omissions. Such occurrences are inherent in the 
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                            C O N T E N T S

                              ----------                              

                        Wednesday, May 13, 2015

                                                                   Page

Assessing the Promise and Progress of the Choice Program.........     1

                           OPENING STATEMENTS

Jeff Miller, Chairman............................................     1
    Prepared Statement...........................................    50
Corrine Brown, Ranking Member....................................     2
    Prepared Statement...........................................    51

                               WITNESSES

Donna Hoffmeier, Program Officer, VA Services, Health Net Federal 
  Services.......................................................     4
    Prepared Statement...........................................    52
David J. McIntyre Jr., President and Chief Executive Officer, Tri 
  West Healthcare Alliance.......................................     5
    Prepared Statement...........................................    61
Hon. Sloan Gibson, Deputy Secretary, U.S. Department of Veterans 
  Affairs........................................................     7
    Prepared Statement...........................................    76

Accompanied by:

    James Tuchschmidt MD, Interim Principal Deputy Secretary for 
        Health, VHA, U.S. Department of Veterans Affairs
Darin Selnick, Senior Veterans Affairs Advisor, Concerned 
  Veterans for America...........................................    38
    Prepared Statement...........................................    87
Carlos Fuentes, Senior Legislative Associate, National 
  Legislative Service, Veterans of Foreign Wars of the United 
  States.........................................................    40
    Prepared Statement...........................................    91
Roscoe G. Butler, Deputy Director for Health Care, Veterans 
  Affairs and Rehabilitation Division, The American Legion.......    41
    Prepared Statement...........................................    99
Joseph A. Violante, National Legislative Director, DAV...........    43
    Prepared Statement...........................................   104
Christopher Neiweem, Legislative Associate, Iran and Afghanistan 
  Veterans of America............................................    44
    Prepared Statement...........................................   114

                             FOR THE RECORD

Danny Breeding...................................................   119
 
        ASSESSING THE PROMISE AND PROGRESS OF THE CHOICE PROGRAM

                              ----------                              


                        Wednesday, May 13, 2015

                  House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 10:02 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present: Representatives Miller, Lamborn, Bilirakis, Roe, 
Benishek, Huelskamp, Coffman, Wenstrup, Walorski, Abraham, 
Zeldin, Costello, Radewagen, Bost, Brown, Takano, Brownley, 
Titus, Kuster, O'Rourke, Rice, McNerney, and Walz.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. Committee will come to order.
    Thank you for joining us this morning for today's oversight 
hearing Assessing the Promise and Progress of the Choice 
Program. We have two full witness panels ahead of us. So I will 
keep my opening remarks short in the interest of time.
    We all know that the Choice Program was created last summer 
to address unparalleled access issues for veterans at the 
Department of Veterans Affairs, and 6 months after it was 
implemented, the program has successfully linked thousands of 
veterans with quality healthcare in their own home communities. 
And I think we can all be proud of that, and I applaud the VA 
and the two Choice Program third-party administrators, Health 
Net Federal Services and TriWest Healthcare Alliance for their 
initial efforts to quickly implement the program and their 
ongoing efforts to make it work well for the veterans who are 
in need.
    That said, the implementation, and administration of the 
Choice Program has been far from perfect. I think everybody can 
admit that, and many veterans are still waiting too long, 
traveling too far to receive the healthcare that they need. 
There are many reasons for this: A lack of outreach to veterans 
who may be eligible; a lack of training for frontline VA and 
TPA staff; a lack of urgency on the part of many VA medical 
facilities who continue to adhere to their old ways of doing 
business. And, of course, I think anyone of us could go on and 
on.
    But during the hearing today we are going to discuss how to 
eliminate impediments to greater veteran and provider 
participation in the Choice Program, and how to ensure that VA 
and TPA staff are properly trained and seamlessly coordinated 
to respond to veteran and non-VA provider questions, and to 
ensure the timely delivery of care. And we will also begin 
discussing where VA goes from here.
    The Choice Program is just one of many ways that VA 
provides care outside of the walls of the Department. All too 
often VA's numerous purchased care programs and authorities 
operate in conflict with one another using different 
eligibility requirements, different programmatic requirements, 
and different reimbursement rates to achieve the very same 
goal. That does not serve VA, the American taxpayer, or, most 
importantly, our veterans and their families well.
    As was stated many times last year, business as usual is 
not an option. Congress has consistently met the 
administration's budget request for the Department of Veterans 
Affairs, and as a result, VA's total budget has increased by 73 
percent since 2009. In comparison, veteran patients have 
increased by only 32 percent since 2009, yet VA has not, and 
cannot, fully meet the needs of the entirety of their patient 
population. This illustrates clearly that VA's failures are not 
a matter of just money. They are a matter of management. There 
is no one way forward, but there can also be no mistaking that 
by challenging VA's failing status quo approach to purchased 
care, we find ourselves at a crossroads of opportunity that 
never existed before.
    I am encouraged by and in agreement with the numerous 
testimonies today that emphasize the need to build a 
coordinated, managed care system that incorporates VA along 
with the needed community options and resources.
    While working to improve the Choice Program today, we must 
all prepare for the Choice Program of tomorrow, one that brings 
the universe of non-VA care together under one umbrella, so 
that the care our veterans receive is more efficient and 
effective, regardless of where it takes place.
    I look forward to working with veterans, with VA, with 
veteran service organizations, and all the interested 
stakeholders on this effort, beginning with the statements that 
you are going to be providing for us this morning.
    I appreciate, again, everybody being here, and with that I 
yield to the ranking member for her opening statement.
    Ms. Brown, you are recognized.

    [The prepared statement of Chairman Jeff Miller appears in 
the Appendix]

       OPENING STATEMENT OF RANKING MEMBER CORRINE BROWN

    Ms. Brown. Thank you, Mr. Chairman, and thank you for 
calling this hearing today.
    As you know, it has been about 9 months since the President 
signed the Veteran Access, Choice and Accountability Act into 
law. This hearing is one in a series of hearings designated to 
follow the progress and abilities of VA to provide healthcare 
to veterans in the 21st century. I am sure we can all agree 
that VA provides the best healthcare for returning veterans in 
this country. However, we all know that there are challenges to 
this mission, and that the VA cannot do it all.
    The Choice Program offers eligible veterans access to 
healthcare that they may not have had in the past. One of this 
committee's highest priorities is to ensure that veterans 
receive the highest quality healthcare in a timely manner and 
in a safe environment. For those veterans who choose to use the 
Choice Program, I want to make sure that this is happening.
    Mr. Chairman, VA have served the special needs of returning 
veterans for 85 years and has the expertise in providing 
services that address their unique healthcare needs. My focus 
continues to be on ensuring that Veterans Affairs retains the 
ultimate responsibility for the healthcare of our veterans. 
Regardless of where they choose to live, the VA is the best 
system we have to serve the healthcare needs of veterans 
returning from war. We cannot allow circumstances that would 
render the system unable to serve the veteran it was built to 
serve.
    The DAV in its submitted testimony said, ``Although the VA 
today provides comprehensive medical care to more than 6.5 
million veterans each year, the VA system's primary mission is 
to meet the unique specialized healthcare needs of the service-
connected disability veteran--disabled veteran.''
    To accomplish this mission, VA healthcare is integrated 
with a clinical research program and academic environment for 
over 100 or more outstanding schools of health professions to 
ensure veterans have access to the most advanced treatment in 
the world. I believe that says it all.
    I look forward to hearing from the Deputy Secretary today 
and all of the witnesses to learn how the VA can better treat 
those veterans who have given so much to defend the freedom we 
all hold so dearly.
    I yield back the balance of my time, Mr. Chairman.

    [The prepared statement of Ranking Member Corrine Brown 
appears in the Appendix]

    The Chairman. Thank you, Ms. Brown, for your opening 
comments.
    Joining us on our first panel this morning is Donna 
Hoffmeier, program officer for VA services for Health Net 
Federal Services, and David J. McIntyre, Jr., president, chief 
executive officer of TriWest Healthcare Alliance. And we are 
also joined by the honorable Sloan Gibson, Deputy Secretary for 
the Department of Veterans Affairs. Mr. Gibson is accompanied 
by Mr. James Tuchschmidt, interim principal Deputy Under 
Secretary for Health.
    Thank you all for being here this morning.
    Ms. Hoffmeier, please proceed with your opening statement. 
You are recognized for 5 minutes.

 STATEMENTS OF DONNA HOFFMEIER, PROGRAM OFFICER, VA SERVICES, 
 HEALTH NET FEDERAL SERVICES; DAVID J. MCINTYRE JR., PRESIDENT 
AND CHIEF EXECUTIVE OFFICER, TRIWEST HEALTHCARE ALLIANCE; HON. 
  SLOAN GIBSON, DEPUTY SECRETARY, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS, ACCOMPANIED BY: JAMES TUCHSCHMIDT M.D., INTERIM 
 PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                  STATEMENT OF DONNA HOFFMEIER

    Ms. Hoffmeier. Thank you, Mr. Chairman.
    Chairman Miller, Ranking Member Brown, and members of the 
committee, I appreciate the opportunity to testify on Health 
Net's administration of the Veterans Choice Program. Health Net 
is proud to be one of the longest serving healthcare 
administrators of government programs for the military and 
veterans communities. We are dedicated to ensuring our Nation's 
veterans have prompt access to needed healthcare services, and 
believe there is great potential for the Choice Program to help 
VA deliver timely, coordinated, and convenient care to 
veterans.
    In September 2013, Health Net was awarded a contract for 
three of the six PC3 regions. We phased in implementation of 
PC3 between October 1 and April 1, 2014. Then in October, 
shortly after Congress passed and the President signed the 
Veteran's Access Choice and Accountability Act of 2014, VA 
amended our PC3 contract to include several components in 
support of the Choice Act. To meet the required start date of 
November 5, we worked very closely with VA and TriWest to 
develop an aggressive implementation strategy and timelines. 
The ambitious schedule required us to develop process flows and 
to hire and train staff very quickly. Despite this aggressive 
implementation schedule, on November 5, veterans started to 
receive their Choice cards and were able to call into the toll 
free Choice telephone number to speak directly with a customer 
service representative to ask questions about the Choice 
Program or to request an appointment for services.
    Having said that, we know there have been challenges that 
have resulted in veteran frustration as well as frustration on 
the part of VA and our own staff. We had less than a week from 
the time we signed a contract modification to go live. With 
such an aggressive implementation schedule, there was little 
time to finalize process flows, educate veterans and community 
providers, and make needed system changes.
    While the collaboration with VA since the start has been 
good, there still is considerable work that needs to be done to 
reach a state of stability where the program is operating 
smoothly and the veteran experience is consistent and 
gratifying.
    We appreciate the opportunity to offer our thoughts on the 
future of the Choice Program. The Choice Program is a new 
program that was implemented, as I mentioned, in record time. 
As a result, there are a number of policy and process decisions 
and issues that are either unresolved or undocumented. If 
Choice is to succeed, these items must be addressed quickly.
    As I stated earlier, we are working very closely with VA to 
address these issues. Many of these issues, however, could not 
have been anticipated prior to the start of the program.
    On the other hand, there are some that should have been 
addressed before the program began, but the implementation 
timeline did not afford adequate time to do so.
    The identification of policy and operational issues and 
concerns has been occurring very quickly. As a result, we have 
struggled to keep up with the developments and to adequately 
train our staff with the most up-to-date and accurate 
information. This situation is not ideal.
    Based on these dynamics, our top recommendation for moving 
Choice forward is to work with VA to develop a comprehensive, 
coordinated operational plan for Choice that clearly defines 
the program requirements, process flows, and rules of 
engagement. This strategy should provide a clear, well-defined 
road map that is communicated to all parties: VISN and VA 
medical center leadership and staff, both contractors, 
Congress, and, most importantly, veterans.
    While the strategy needs to clearly identify key 
initiatives and reasonable timelines for implementing those 
initiatives, it also needs to contain the flexibility to 
quickly address issues as they arise, and to make necessary 
course corrections. Key components must include resolution of 
outstanding policy and process issues, which currently are 
numerous; development of policy and operational guides that are 
mandated across the program; comprehensive training of 
contractor and VA staff using consistent process flows, 
operational guides, and scripting; and a clear and responsive 
process for resolution of legitimate issues and challenges.
    In closing, I would like to thank the committee for its 
leadership in ensuring our Nation's veterans have prompt access 
to needed healthcare services.
    I also would like to thank you Congresswoman Brown for your 
leadership in helping to educate veterans and community 
providers on the Choice Program. The meetings you convened with 
veterans and community providers in Jacksonville were 
invaluable. We appreciate the opportunity to participate in 
those meetings. We are committed to continuing our 
collaboration with VA to ensure that the Choice Program 
succeeds. Working together and with the support and leadership 
of this committee, we are confident that Choice will deliver on 
our obligations to this country's veterans.
    Thank you, Mr. Chairman.

    [The prepared statement of Ms. Hoffmeier appears in the 
Appendix]

    The Chairman. Thank you very much.
    Mr. McIntyre, you are recognized for 5 minutes.

              STATEMENT OF DAVID J. MCINTYRE, JR.

    Mr. McIntyre. Chairman Miller, Ranking Member Brown, and 
members of the distinguished committee, it is a privilege to be 
back before you on behalf of our company's nonprofit owners and 
its employees as you assess the promise and progress of the 
Veterans Choice Program.
    Mr. Chairman, I stood this morning reflecting on the 
quietness of the Disabled Veterans Memorial at the base of the 
Capitol, which was built to honor the sacrifices of those whom 
we all count as our heroes. I thought of the conversation you 
and I had there that morning of its dedication. Your question 
to me was whether Choice would be operational on November 5. 
You stressed the importance of being ready on time, although 
you admitted that it was a tall order. And you may remember I 
assured you that I was confident that the VA, our colleagues at 
Health Net, and we would not fail in the task.
    Following the ceremony, grounded in what my 
responsibilities were, I flew back to Arizona to start the 
design and construction process with my team, along with the 
teams from VA and Health Net with an intensity and purpose that 
endures to this day.
    We continue our collaborative work to ensure that the 
paradigm shift you and nearly every Member of Congress sought 
in the passage of the Choice Act. Indeed, just as you defined 
on November 5, the reality did start to take hold, as together 
we stood up the Choice Program on time. We got cards out with 
an individual letter from the Secretary to each veteran, and we 
started taking phone calls.
    But, of course, that was just the beginning. Now we have 
work to do to make sure that we refine the program that you 
wanted to see brought into place.
    Just like the start of the TRICARE program nearly 20 years 
ago, which I was privileged to be a part of, along with my 
colleagues at TriWest, there was a lot of work to do to achieve 
the promise of that program and mold it into what's become one 
of the best health plans in America. Back then, it took a 
highly collaborative effort between Congress, the Defense 
Department, private sector contractors, beneficiary 
associations, and the VSOs. The same will be true, I believe, 
of this program, and I believe the same promise exists with 
this that exists with TRICARE.
    As we discussed at the last hearing at which I appeared 
before the Veterans Choice Program, there was PC3. Actually, 
PC3 was responsible for assisting the Phoenix VA in addressing 
the backlogs that were uncovered on April 9. Sixty-three 
hundred providers in Maricopa County leaned forward at the side 
of the VA in Phoenix to take care of the more than 14,000 
veterans that were backlogged, and we did it by August 17 
together.
    Now, at the end of the day, that network alone was not 
going to give us the types of choices that you felt were 
necessary in order to make this all work. So we continued to 
grow a network. We now have 100,000 providers contacted in 28 
States and the Pacific, and over 4,500 facilities, which 
include academic medical centers to the tune of about 40 of the 
academic--40 percent of the academic affiliates that are in our 
area of responsibility.
    Just yesterday the University of California at San Diego 
signed a contract to be part of the partnership that has been 
birthed collaboratively in San Diego.
    So, yes, we stood it up on time. But as we know, there is a 
fair amount of work still to be done. We have now refined, at 
least for the first increment, the 40-mile drive distance. We 
have gone from ruler to drive time. We are conducting training 
and more outreach. We are accelerating the transfer of the 
daily eligibility file requirement that needs to occur. And we 
are concluding a pilot in how we will share clinical 
information on a more timely basis so that the needs of 
veterans and the information that providers might need would be 
at the core of what we are doing. There is a clinical policy 
work group that is meetings on a regular basis to define the 
gaps that need to be closed in that space.
    At the end of the day on our end, we are refining our 
customer service. We are establishing a new IT platform that we 
will be rolling out just after Memorial Day after a 24/7 build, 
and we are seeking from the opportunity to work collaboratively 
in the marketplace to make sure that the networks are tailored 
to match the precise demand that a VA facility has. That work 
is underway.
    We need a couple of things from you. One is, I think we 
should be revisiting the question of whether a 60-day 
authorization limitation makes sense. Secondly, there is a 
need, from my perspective, to harmonize the differences between 
the PC3 program and the Choice Program so that we can make sure 
that we are leveraging those networks about which I spoke.
    Volume is coming. Visits have been made to El Paso, Las 
Vegas, and other markets. On Friday I will be in Memphis 
working with the team there.
    Mr. Chairman and members of the committee, supporting the 
care needs of American's veterans is a tremendous honor and 
privilege. We thank you for that opportunity. We thank the VA 
for the partnership, and we look forward to working at your 
side in achieving the promise that Choice presents to America's 
veterans and their families.
    Thank you, Mr. Chairman.

    [The prepared statement of Mr. McIntyre appears in the 
Appendix]

    The Chairman. Thank you, Mr. McIntyre.
    Mr. Gibson, you are now recognized for your opening 
statement.

                 STATEMENT OF HON. SLOAN GIBSON

    Mr. Gibson. Chairman Miller, Ranking Member Brown, members 
of the committee, we are committed to making the Choice Program 
work and to providing veterans timely and geographically 
accessible quality care, including using care in the community 
whenever necessary.
    I will talk shortly about what we are doing and the help we 
need from Congress to make that happen.
    First, I want to talk briefly about improvements in access 
to care. Most mornings at 9 a.m. for the last year, senior 
leaders from across the Department have gathered to focus on 
improving veterans' access to care. We have concentrated on key 
drivers of access, including increasing medical center staffing 
by 11,000, adding space, boosting care during extended hours 
and weekends by about 10 percent, and increasing staff 
productivity. The result? 2.5 million more completed 
appointments inside VA this past year. Relative value units, 
RVUs, our common measure of care delivered across the 
healthcare industry, are up 9 percent. Another focus area for 
improving access has been increasing the use of care in the 
community.
    In 2014, VA issued 2.1 million authorizations for care in 
the community, which resulted in more than 16 million completed 
appointments. Year-to-date 2015 authorizations are up 44 
percent, which will result in millions of additional 
appointments for community care. Veterans are responding to 
this improved access. More are enrolling for VA care. Among 
those enrolled, more are actually using VA for their care, and 
among those using VA, they are increasing their reliance on VA 
care. This is especially the case where we have been investing 
most heavily due to long wait times.
    In Phoenix, where we have added hundreds of additional 
staff, we have increased completed appointments 20 percent. 
RVUs are up 21 percent, and authorizations for care in the 
community are up 123 percent. Much of that in thanks to TriWest 
Healthcare and their support of care in the community there in 
the Phoenix market.
    But wait times aren't down, because veterans continue to 
come to VA in increasing numbers to receive their care. In Las 
Vegas, we have got a 17 percent increase in veterans receiving 
care since we opened the new medical center there. In Denver, 
we have opened outpatient clinics and added more than 500 
additional staff. Veterans using VA are up 9 percent. In 
Fayetteville, North Carolina, where wait times continue to be a 
problem, we have increased appointments 13 percent. Veterans 
using VA for care are up 10 percent. And in all of these 
locations, we have had dramatic increases in care in the 
community.
    As Secretary McDonald has testified during budget hearings, 
the primary reasons for increasing demand are, one, an aging 
veteran population; increases in the number of medical 
conditions that veterans are claiming; and a rise in the degree 
of their disability; and as we can see here, improving access 
to care.
    As I mentioned at the outset, community care is critical 
for improving access. We use it, and we have for years, in 
programs other than Choice.
    In fiscal year 2013, VA has spent approximately $7.9 
billion on community care other than Choice. In 2014, that rose 
to $8.5 billion, and we estimate that at the current rate of 
growth, VA will spend approximately $9.9 billion, including 
Choice, roughly a 25 percent increase in just 2 years.
    At the same time, we have had a large increase in care in 
the community, Choice has not worked as intended. Here are some 
of the things that we are doing to fix it. On April 24, we 
changed the measurement from straight line driving distance 
using the fastest route. This roughly doubles the number of 
veterans eligible for 40 miles under Choice. But there is much 
more to do. A follow-on mailing to all eligible veterans is 
about to go out. We have just launched a major change in 
internal processes to make Choice the default option for care 
in the community; additional staff training and communication; 
extensive provider communications; improvements to the Web site 
and ramped-up social networking; new mechanisms to gather 
timely feedback directly from veterans as well as directly from 
frontline staff. These are all already underway, or in the 
process of being launched.
    In the longer term, we must rationalize community care into 
a single channel. The different programs with different rules, 
different reimbursement rates, different methods of payment and 
funding routes are too complicated. They are too complicated 
for veterans; they are too complicated for providers; and they 
are too complicated for our employees who are trying to manage 
care. I expect that we will need your help on that change.
    Next, let me touch on the other 40-mile issue. We have 
completed in-depth analysis using patient level data to 
estimate the cost of a legislative change to provide Choice to 
all veterans more than 40 miles from where they can get the 
care they need. We have shared that analysis with some members 
of this committee, with staff, and with the CBO. It confirms 
the extraordinary cost that has been estimated previously. We 
have also briefed the staff on a broad range of other options 
and believe there are one or more options worthy of discussion 
and very careful consideration.
    While we are working together on an intermediate term 
solution, we are requesting Congress grant VA a greater 
flexibility to expand the hardship criteria in Choice beyond 
geographic barriers. This authority would allow us to mitigate 
the impact of distance and other hardships for many veterans. 
We need greater flexibility around some requirements that 
preclude us from using Choice for services such as obstetrics, 
dentistry and long-term care. We also ask for modification of 
the 60-day authorization period set forth in the law to bring 
this more in line with industry standards.
    As described above, we accelerated access to care in the 
community this year anticipating a substantial portion would be 
funded through Choice. For various reasons, most touched on 
previously, we will be unable to sustain that pace without 
greater program flexibility and flexibility to utilize at least 
some portion of Choice Program funds to cover the cost of other 
care in the community. We are requesting some measure of 
funding flexibility to support this care for veterans.
    On May 1 VA sent to Congress a legislative proposal 
providing major improvements to VA's authority to use provider 
agreements for the purchase of community care. We request your 
support.
    Lastly, we are requesting flexibility in one other area of 
veteran care: Hepatitis C treatments. You are all familiar with 
the miraculous impact of the new generation of drugs. Veterans 
that have been Hep C positive for years now have a cure within 
reach with minimal side effects. Because of the newness of 
these drugs, there was no funding provided in our 2015 budget 
request.
    We moved $688 million from care in the community 
anticipating a shift in cost for that care to Choice to fund 
treatment for veterans with these new drugs. It was the right 
thing to do, but it was not enough. We are requesting 
flexibility to use a limited amount of Choice Program dollars 
to make this cure available to veterans between now and the end 
of fiscal year.
    So, we are improving access to care. We are committed to 
making Choice work and have very specific actions underway to 
do just that. And we need some help, especially additional 
flexibility to make it possible for us to meet the healthcare 
of our veterans.
    We look forward to your questions.

    [The prepared statement of Mr. Gibson appears in the 
Appendix]

    The Chairman. Thank you very much. I think we can all agree 
that using the new generation of drugs is critical for not only 
the veteran but the long-term cost associated with that.
    My question is, what did you request in the 2015 budget? 
Was there $100 million or nothing? What----
    Mr. Gibson. For the new generation of drugs, my 
understanding is that in our request, there was not any funding 
for the new generation of drugs. When you go back and look at 
the timeline of these drugs being approved and the expected 
utilization, we didn't have any kind of clarity at the time of 
the 2015 budget request.
    The Chairman. Is that because you didn't know what the cost 
of the drug was going to be? You knew what your parameters were 
as far as the veterans that were already testing positive for 
Hep C. Correct?
    Mr. Gibson. We have maintained a working list of veterans 
that have tested positive for Hepatitis C. I think the 
questions had to do with what drugs had been approved at the 
time we were formulating our 2015 budget request and what the 
costs for those drugs would be and then the anticipated 
utilization.
    The Chairman. Thank you.
    Mr. McIntyre, in your written statement you reference some 
VA facilities that have, and your quote was, ``simply continued 
to use almost exclusively their historical non-VA care program 
to buy care from the community providers,'' end quote rather 
than using the Choice or the PC3 programs. So can you tell us 
where the facilities are? We need to know why they are choosing 
to do that, and is it in, obviously, a particular geographic 
region of the country?
    Mr. McIntyre. Congressman Miller, the VA central office is 
completely engaged in that topic now as a result of a 
conversation about 6 or 7 weeks ago where we stress tested on 
both sides the question of whether direct contracts made sense 
when it was the case that we had actual networks established, 
and in some cases, established with exactly the same providers 
in the community. And the Department stress tested that 
question with us directly, and we have arrived at the 
conclusion, I believe, based on the behavior of where we are 
headed, that to the degree that we have networks that are 
developed, that those are the networks that would be used for 
the purpose of delivering care unless they needed to themselves 
be augmented.
    So I will go to Dallas, Texas for a second where we had a 
meeting a few weeks ago. We looked at the entirety of demand 
between myself, the VAMC director, and the VISN director at the 
same table with the entire staff to determine what demand they 
had for everything in the marketplace, and what the network 
looked like juxtaposed to that demand. And then made the 
decision at that table that they would be buying their care 
through that network. We have one more piece to fill in. That 
is the same conclusion that was reached in Phoenix right after 
April 10. That is the same conclusion that was reached in 
Hawaii. We now have an entire network built out in that market, 
and it got done collaboratively.
    So to the degree that we want to leverage the capabilities 
of the two organizations that have been hired to support the 
VA, we need the right tools, we need the right collaboration, 
and then we need to make sure that there is discipline on the 
other side so that unlike in Albuquerque, New Mexico, where we 
happen to have the University of New Mexico in our network, but 
they also have a direct contract, and 85 percent of the care 
moves through that non-contracted environment on our side at a 
higher cost to the taxpayer, we need to start to transition 
these things with the discipline that is needed. And I believe 
that the senior leadership responded smartly and appropriately 
7 weeks ago, and we have been on a series of visits ever since. 
The next one of which will be in Memphis, Tennessee on Friday.
    Dr. Tuchschmidt. If I could, Mr. Chairman, just to add that 
we have issued guidance to our facilities to use the Choice 
Program as the preferred way of gaining care in the community 
for veterans when we cannot treat them in a timely way. So the 
first option is to find a VA facility that, in fact, can 
provide that care, and if we can't provide that care within the 
time standard that we have, that we use Choice as the 
preferential channel for which we get that care.
    And we are working right now with both TriWest and Health 
Net to contact the roughly 87,000 physicians and providers that 
have been delivering care to veterans who are normal otherwise 
non-Choice purchase care mechanisms to reach out to those folks 
and to try and get them to join the network so that they can 
continue to provide care to our patients.
    The Chairman. Thank you.
    Ms. Brown.
    Ms. Brown. Oh, I am sorry.
    The Chairman. Mr. Takano.
    Ms. Brown. Then I will have the last statement.
    Mr. Takano. Thank you, Madam Ranking Member. Thank you, Mr. 
Chairman.
    Mr. Gibson, you know, a very real concern of mine is that 
for the Choice Program to be successful we need to guarantee a 
robust supply of non-VA providers to care for our veterans in a 
timely manner. In my district, and I know many of my colleagues 
on this committee face the very same issue, we have several 
primary care and mental health shortage areas. Our providers 
are already stretched thin trying to care for the non-veteran 
population. We have to do more to train providers and attract 
them to underserved areas. And that is why I worked with 
Representatives Titus and O'Rourke to include the 1,500 GME 
residencies in the Choice Act.
    You mentioned that the initial 200 residencies, in your 
statement, that the VA has awarded those initial 200 
residencies. Can you give me more detail about the VA strategy 
for awarding these residency slots?
    Dr. Tuchschmidt. Sure. Yes. We had about 330-plus requests 
for new residency slots this year. The intention is to use 
those 15 and stand up those 15 slots over a roughly 5-year 
period. I, quite frankly, was surprised that we were going to 
have as many requests for July as we did. And as you have said, 
we have awarded 204 positions.
    There are criteria in the law that they are for scarce 
specialties, scarce medical disciplines, and in scarce areas. 
Right? So those are the criteria that we have awarded.
    This year, roughly 74 of those slots are primary care 
slots, 58 of them are mental health slots, and 38 of the slots 
went to new or expanding programs in--residency programs in the 
country. We had a lot of requests from new programs that were 
starting, particularly in rural areas. We don't own these 
residency slots, the universities do, and then we are basically 
financially supporting those slots and supporting the training 
opportunity for those residents.
    New places, particularly smaller places, have to meet 
certain standards to be--for those programs to be accredited, 
and they were just not ready yet to accept those positions, I 
think.
    So we have--we are following the criteria that are in the 
law, targeting hard-to-recruit specialties and rural areas, and 
I think that next year as we get into the second round of this 
we are going to find that there are a lot more of the smaller 
programs, new programs, that are actually going to be up and 
ready to run those programs.
    Just to make this--kind of bring the point home, when we 
establish a new residency in one of our VA facilities, there 
have to be call rooms for those residents to sleep in. There 
have to be work spaces for them to work in. All that kind of 
stuff. There has to be qualified faculty at that VA medical 
center to be able to do that work. So you have to recruit that 
faculty. You have to do the interim projects to have the 
sleeping quarters and all that kind of stuff, and that is kind 
of where we are in the process.
    Mr. Takano. Well, Mr. Tuchschmidt, I appreciate all that, 
what you told me. I am surprised that you were surprised that 
you had so many applications because, as you know, there is a 
tremendous shortage of GMEs across this country, especially in 
rural areas. And I am wondering if there are ways that we can 
look at more flexibility as to how we deploy these residencies, 
because they are key to the maldistribution of providers in our 
country. They tend to gravitate toward areas which already have 
a robust medical infrastructure, and there are certain parts of 
our country, especially in the southwest and the rural areas 
that need these--as you know, where the residencies are located 
are key to where these physicians actually will choose to 
practice for the rest of their lives. 60 percent--we have a 60 
percent chance of capturing a resident, and in areas like mine 
where we have a shortage of physicians in the non-VA 
population, I see--and I understand that we have a shortage 
within the VA, you know, physicians, and your ability to 
compete for those physicians to actually work at the VA is--if 
you are in competition with an environment of a shortage of 
physicians, we have a real problem. And I would submit to you 
that we need to work together to increase the level of GMEs, 
generally, for the VA and non-VA population to really handle 
this wait list problem.
    Mr. Tuchschmidt. Absolutely. And I am happy to go back and 
talk with our academic folks to see if there is some additional 
flexibility that we might need to be able to do this.
    And I was only surprised because we were starting out of 
cycle for the first----
    Mr. Takano. This is truly something where red States and 
blue States should become purple. Don't you think?
    Great. Thank you.
    I yield back, Mr. Chairman.
    The Chairman. Thank you.
    Dr. Roe.
    Dr. Roe. Thank you, Mr. Chairman, and thank you all for 
being here today.
    I am going to read you a letter just very quickly from a 
veteran service officer.
    ``Dear Bill,'' and that is one of my district people, 
``Nice to see you again this week in Morristown. Per our 
conversation regarding the veterans Choice card, all I've heard 
from local veterans in Hawkins County is it's a joke. 
Personally, I called the toll-free number and was told by a 
lady that the area I lived in was not programmed in. I was told 
to call back in 7 to 10 days to check if the information was 
available. This was in December after the October rollout. I 
also heard from a few veterans who were told because of 
residing in the immediate Rogersville area, we had a VA 
facility and they could attend there after obtaining their own 
appointment. They were referring to our CBOC, which has only 
one primary care doctor, and, by the way, that's the only 
doctor there who's overworked due to patient load. No specialty 
physicians are located in our CBOC. Hearing other disgruntled 
stories throughout the Tennessee Department of Veterans Affairs 
poorly training, I must agree with my fellow veterans I serve, 
the program is a joke indeed.
    Some common sense needed to be implemented before the 
program was rolled out, mainly the miles issue, and of course 
realizing the difference between a CBOC and a VA medical 
center.'' And then he goes on to say, ``I use the VA healthcare 
pretty much exclusively. I have only good things to say about 
my treatment. I am just thankful I hadn't had to depend on the 
Choice card for my care. With my service-connected PTSD, I 
would probably make a fool of myself. With best regards, 
Congressman Roe.''
    So that is what one VSO said. A little bumpy on the 
rollout.
    A couple of other things that I want to bring up that has 
bothered me with any government program, whether it is the VA 
or anything else, and this number may be wrong, but we just 
knew there were veterans out there that could not get care, so 
rolled this program out, and according to our staff memo here, 
it says, ``As of last week, 53,828 Choice authorizations have 
been made, and 43,044 appointments have been scheduled.''
    We have spent $500 million doing that, which is $11,616 per 
appointment. That seems a little high. And I wonder why that 
is, why the administrative costs gobble up more money than the 
care going to the veteran. That just--it boggles my brain, 
although I will tell you it is actually better than 
healthcare.gov in Hawaii which was $24,000 per customer. So you 
actually are doing half of what they charge in cost. And there 
are programs out there, whether it is TriWest or Medicare, 
whatever, systems that already work. Now, I realize putting a 
network together is difficult. I do know that. That is a big 
deal you are trying to do countrywide. It is a huge deal.
    And another question I have, I guess, Mr. Secretary, for 
you, you said about the 40-mile limit. How much would it cost 
to do that? You didn't mention that. You said it was expensive, 
but you didn't put a number on it.
    And, secondly, why are we using the veterans Choice card? 
This was to reduce the backlog, not to just provide service for 
veterans. Why are we going to that pot of money instead of 
using money the VA already has in its budget for that? And that 
was mentioned, and I would like to know why that is going on, 
because I shouldn't be.
    Mr. Gibson. I am not sure I understood the last question. 
Why----
    Dr. Roe. Well, he just said just a second ago that they 
were funneling the veterans to the Choice program, not to a 
program that already exists for their care outside the VA.
    And, lastly, concerns I have heard over prompt payment--we 
talked a lot about that when we were doing this bill, and 
prompt in the VA in payment is an oxymoron.
    Mr. Gibson. Which of those questions would you like for me 
to tackle first?
    Dr. Roe. Any of them.
    Mr. Gibson. I will start from the end, and then probably 
have to ask for a reminder.
    On prompt payment, you are absolutely right. We are 
historically--as I have said in the past, we pay low and slow. 
And that is a challenge for providers.
    One of the things that Congress did for us, thank you very 
much, is you required us to consolidate our payment processing 
organization at least into a single reporting channel. We were 
processing payments in 21 different locations--in 21 different 
organizations in 77 different locations. We have now 
consolidated the--at least the reporting relationship, and we 
are now beginning to tackle some of the tough issues that were 
just being worked around in the past, and as a result, not 
providing timely payment to providers.
    Frankly, the situation has been exacerbated by our 
acceleration of referral to care in the community. In the first 
4 months of this year, the number of claims coming in the door 
are up 42 percent. So not only are they trying to catch up from 
the past, they are trying to stay ahead of that kind of a bow 
wave.
    So we are after it in a big way. It bears directly on 
access to care because we have got to have providers out there.
    I would remind you that under Choice, the providers get 
paid by the TPAs, and the stipulated requirement in the 
contract is 30 days.
    What is the next question that I need to answer?
    Dr. Roe. My time is expired, but I will submit those to you 
because there are several important questions I want the answer 
to. And I would like to have this letter submitted for the 
record.
    Mr. Gibson. And I would be delighted to answer them.
    The Chairman. Without objection.

    [The prepared statement of Sloan Gibson appears in the 
Appendix]

    The Chairman. Ms. Titus, you are recognized.
    Ms. Titus. Thank you, Mr. Chairman.
    Mr. McIntyre, you mentioned in your written statement that 
the current rules might require a pregnant veteran to change 
doctors during the course of her pregnancy, and that just kind 
of draws attention to something that I have been working on to 
try to be sure that our women veterans get the kind of 
healthcare services that they need. So I would ask you if you 
have discovered any patterns or any trends of differences 
between men and women who are using the Choice program? Any 
tendencies for women to go outside of the VA perhaps more than 
men for OB/GYN treatment? Can you answer some of those 
questions so we can be sure that women are being served by this 
program as well?
    Mr. McIntyre. Yes, ma'am. And thank you for your critical 
leadership in that area.
    I think it is really early to tell what the patterns are 
going to look at the end of the day. We have got about 42,000 
auths for Choice that have moved through our fingertips over 
the last several months since this started, and many of them 
are in--certainly for women's services issues. We could get you 
a listing of what that looks like and what the volume is 
juxtaposed to other types of services that are being requested. 
We do have OB/GYNs in the network.
    We also have a responsibility that to the degree that 
mammograms aren't available, OB/GYNs aren't available and the 
like, and they are needed and unavailable in the VA, to 
actually contact a provider on the veteran's behalf and place 
them with a provider of their choice.
    And then as Secretary Gibson said, to pay within 30 days on 
average. That is actually what we are doing now. Three months 
ago we were at 90 days. Now we are on average at 30. So we are 
hitting that speck.
    And the focus on women's health issues is really, really 
important to all of us. We appreciate their service, and we 
look forward to collaborating with you, particularly as it 
relates to Las Vegas on that and the other issues in your 
community.
    Ms. Titus. I appreciate that, and it is so important 
because many of the VA facilities don't have a resident OB/GYN, 
and so we want to be sure that they are getting that service. 
And I especially appreciate you saying that you want to 
collaborate. I heard you mention you had been to Las Vegas, but 
Ms. Hoffmeier said that she had been willing to do roundtables 
with veterans, not just meeting with the doctors. And I wonder 
perhaps you could partner with me and we could do a roundtable 
so we can get the word out about the Choice program in----
    Mr. McIntyre. Ma'am, that would be fabulous. You name the 
time, the place, the date, and I will be there.
    Ms. Titus. And I got a lot of witnesses here.
    Mr. McIntyre. Done. And what I will tell you, ma'am, is 
this. It is not the only time I have been to Vegas.
    Ms. Titus. Well, that is good. We like that too. So----
    Mr. McIntyre. Not for gambling. I have been there not to 
leave money in the economy. I have been there to work, and we 
have been there four times now to meet with the facility and 
work on tailoring the network related to the demands in that 
market. And they are leaning forward and doing what they need 
to be doing on their end on your behalf.
    Ms. Titus. Great. Thank you. We will set that up.
    Mr. Secretary, I--thank you. It is always a pleasure to see 
you, but before I ask a question, I want to just take a minute 
to associate myself with the comments that were made in the 
veterans hearing on the Senate side yesterday by Ranking Member 
Blumenthal. He is very concerned, as I am, about taking money 
from the Choice Act to pay for those outrageous overruns in 
Aurora, and we need to help the veterans in Denver, but we 
can't take money from a program that you all said you needed, 
you needed this money, to serve all our veterans. And now to 
just say: Oh, well, we don't really need that $700 million, I 
don't think is acceptable, and I would like for the record to 
show that.
    Also my question, though, is that you mentioned that you 
all are in the process of hiring more than 10,000 medical 
professionals.
    What my question is--is that to fill a gap, to fill a hole, 
or to fill vacancies, or is that in anticipation of needs of 
the future? Because there is some parts of the country where 
the veteran population is growing, like Mr. O'Rourke's 
district, my district. Other places the veterans population not 
so much.
    Could you address that?
    Mr. Gibson. Of course, yes. In fact, the comment in my 
opening statement was that we had grown net 11,000 medical 
staff in our medical centers over the last 12 months. We are at 
any point in time, and we are right now, the number I am 
remembering, Jim may have a better number, is somewhere on 
order of 28,000 individual positions that we are working to 
fill all across VA. That number bumped up because of the Choice 
Act, because of the number of positions that we are working to 
fill, that were made possible by that incremental funding. But 
in the course of our routine turnover, we see between 8 and 9 
percent turnover, substantially less than what you see in the 
private sector in healthcare, but when you look at a staff of 
some close to 300,000, if you are turning over 8 or 9 percent a 
year, you are going to have a large number of vacancies open at 
any point in time. So we are constantly recruiting to fill 
vacancies across VHA.
    Ms. Titus. Thank you. And we hear a lot about the shortage 
of doctors, but I know there is a shortage of nurses and other 
technicians as well. So we need to be aware of that problem 
too.
    Mr. Gibson. You are absolutely right. Yes, ma'am. We are 
the largest employer of nurses in the country, and that is a 
vital position for us to ensure that we are effectively 
recruiting.
    Ms. Titus. Thank you.
    Thanks, Mr. Chairman.
    The Chairman. Mr. Huelskamp.
    Mr. Huelskamp. Thank you, Mr. Chairman. I appreciate you 
calling this hearing, as well as your great work on expanding 
choices for our veterans, and I----
    Mr. Under Secretary, I do appreciate your statement that 
Choice is now the default option for care outside the VA, and I 
will look forward to some description of how you made changes 
to make certain that happens.
    What I want to ask--a couple things. First of all, I find 
out in this committee we have a lot of differences across our 
districts, and some have more or less providers, but in my 
Congressional district, we have about 70 community hospitals 
and zero VA hospitals. And what I am hearing from those 
hospitals is a tremendous difficulty of getting into--as an 
approved provider. They can do it for Medicare. They certainly 
can do it for TRICARE. But it is extremely difficult.
    What I would like to ask the TriWest folks is, what does 
the VA need to do to make sure that these community hospitals 
that want to serve veterans get in and become an approved 
provider? What can we do differently?
    Mr. McIntyre. Well, I think we should compare notes because 
we have a fairly sizeable network built out in Kansas, and it 
may be that some think they are not under contract because we 
used to do the TRICARE work in the State of Kansas, and they 
actually, in fact, have a network contract to do the work for 
this work.
    And actually Dr. Tuchschmidt and I discovered that similar 
problem in Bend, Oregon. Didn't we, sir? Where someone decided 
to light both of us on fire, and at the end of the day, within 
a couple hours, they were trying to explain why it was that 
they had mistaken the fact that they actually were under 
contract.
    So I would look forward to that dialogue. We have a broad 
footprint in Kansas. If we need to add it, we will definitely 
make that happen, because we are responsible for making sure 
that the care is accessible.
    Mr. Huelskamp. And I appreciate that, and maybe it is the 
folks at the VA that are answering the phone, because it is 
still extremely difficult. We have veterans that are making it 
through the system and getting those choices. As I have talked 
about again and again in this committee, it is usually they 
talk about hours to get to a provider and--when they have a 
local hospital down the road, and they are still not getting 
the yeses that they need.
    And one of the other things, as far as yeses, I would like 
the Under Secretary to know about this. At Fort Riley, which is 
in my district as well, they are building a brand-new hospital, 
and there are--sometimes they say it takes years for the VA and 
the DoD to come together to agreement, and the CBOC there is a 
limited primary care. Actually, all the CBOCs are very limited, 
which I want to get to in another question, but I wanted the 
Under Secretary to understand that the folks there would like 
access. They would--you know, they can serve 10 years at Fort 
Riley. They would like to step off the base and turn around and 
still access the care that they have been doing as well.
    So the last question of Mr. Secretary would be in reference 
to the hardship exemption. And how far can you stretch that to 
meet the needs of these veterans of rural communities to get 
past this artificial 40-mile barrier, and say, Hey, you know 
what? The CBOCs are not offering the care, and it makes no 
sense to calculate 40 miles to a place that doesn't offer 
anything other than maybe primary care, maybe 4 days a week, 
maybe 1 day a week, and describe how we can expand that and 
meet those needs?
    Mr. Gibson. First, very briefly, everywhere I go I find a 
very strong relationship between the local VA and DoD medical 
facilities. I will make sure--I have not been to Kansas yet, 
but I will make sure that we are working to build that 
relationship with Fort Riley.
    Secondly--the second question is?
    Mr. Huelskamp. Hardship exemption, and how we can use the 
current law and still expand beyond this artificial----
    Mr. Gibson. Yeah. Well, the flexibility that I referred to 
here and that we are requesting, the way the language is 
written right now it has to do with a very limited and very 
narrow geographic barrier. What we are looking for is much 
broader discretion so that, you know, for example, the veteran 
that you described in your letter that we would be able to, 
much more liberally, address those particular needs for that 
veteran in terms of the distance traveled and be able to rely 
on the Choice program to fund that.
    I would tell you, part of our challenge here, and I didn't 
get a chance to answer that part of Dr. Roe's question, as we 
run even the most conservative assumptions, we are seeing 
numbers on the order of magnitude of $10 billion a year. So 
just completely open the aperture. And--and so part of what we 
are looking at here as an interim solution is the idea that we 
would have that kind of discretion. And I might say, for 
example, if a veteran needs a knee replacement, then traveling 
some considerable distance to get that knee replacement, maybe 
that is not unreasonable in order to get it done at a VA 
hospital. What I don't want to have is that veteran having to 
travel that same distance to get the physical therapy done 
after he has the procedure.
    Mr. Huelskamp. And I am out of time, Mr. Under Secretary. 
One last point. And appreciate that. I would ask you to look at 
the hardship exemption to get past this artificial 40-mile 
barrier as well. And as far as your cost estimates, I don't 
know if you have done the comparison, but I find it hard to 
believe that you are doing it more effective and more cheaply 
than our TRICARE and Medicare system, which is dozens and 
dozens and dozens, and perhaps hundreds of choices, and in 
the--in my congressional district, very few choices for VA. So 
that is a comparison I would like to see.
    So I yield back, Mr. Chairman.
    The Chairman. Mr. O'Rourke.
    Mr. O'Rourke. Thank you.
    Mr. Gibson, at one point in your opening statement, you had 
mentioned spending up to $9.9 billion, including Choice on 
outside care.
    What year were you talking about, and what was the amount 
for Choice specifically?
    Mr. Gibson. Well, we are--what I am talking about is on the 
pace that we are on right now, I expect that we are going to 
spend close to $10 billion on care in the community.
    Mr. O'Rourke. By what date?
    Mr. Gibson. Pardon me?
    Mr. O'Rourke. By what date?
    Mr. Gibson. This fiscal year.
    Mr. O'Rourke. Okay.
    Mr. Gibson. This fiscal year between October 1 of 2014 and 
September 30 of 2015. This fiscal year that we would spend just 
under $10 billion. The challenge that we have is, for a whole 
bunch of reasons, many of which are internal, some of which we 
are challenged around in terms of flexibility provisions and 
things like that, the majority of that has been coming out of 
our--out of our traditional VA community care budget. We cannot 
sustain that.
    So part of what Jim was describing earlier about--about 
shifting to make Choice the default option, that is--no pun 
intended--that is not a choice. We have no alternative but to 
do that, because otherwise we won't be able to refer veterans 
to care in the community. And without additional flexibility, 
there will be other instances where we would otherwise have 
referred the veteran to care in the country but we don't have 
the dollars to pay for it.
    Mr. O'Rourke. So having said that, and then you also said 
in your opening remarks that you wanted to rationalize Choice 
and community into one channel.
    Mr. Gibson. Yes.
    Mr. O'Rourke. And a request for flexibility. Is the logical 
conclusion of that that you would just merge those programs 
into one? And do we need Choice? Should all this go through 
PC3? Should all of PC3 go through Choice? Do we just need one 
program?
    Mr. Gibson. Let me, if I may, take one moment, and then I 
want--because there is context for the answer.
    I mention in my statement that we had reviewed with the 
staff, and we are delighted to do that with members, an array 
of alternatives that we have been looking at to just basically 
saying 40 miles from wherever you can get the care. They have 
to do with limiting it to certain services, limiting it to 
certain priority groups, and--and then doing some different 
things in terms of pay structures.
    One of the alternatives that I think is particularly 
interesting and warrants careful consideration is the idea, and 
this affects other parts of the Federal Government that--let me 
back up.
    VA care--the veterans who we are providing care to right 
now, 81 percent have either Medicare, Medicaid, TRICARE, or 
some form of private insurance. And so part of what we are 
seeing as we cost out this $40 billion from where you can get 
the care is a material shift out of Medicare and other primary 
payers into VA because we don't have the co-pay levels that you 
find in these other programs. So one idea is you eliminate that 
economic distortion in the veteran's decision. You make, for 
example, Medicare the primary payer. You use VA as--to 
indemnify the veteran up to their Medicare co-pay, and all of a 
sudden, you have done something to give real choice to the 
veteran, and, frankly, more efficiently for the taxpayer, so 
that the taxpayer is not paying twice for the same kind of 
care.
    And the base question I am answering here is?
    Mr. O'Rourke. Well, I was asking about whether the logical 
conclusion of this is that we are merging the two programs. But 
I also want to get a question to Mr. McIntyre.
    Mr. Gibson. But as you go to that kind of a scenario, then 
you step back from that and you ask yourself: How do you 
optimally organize to execute that?
    Mr. O'Rourke. Yes.
    Mr. Gibson. And I still think it is one single channel.
    Mr. O'Rourke. Yes.
    Mr. Gibson. We can't operate in five or six or seven 
channels.
    Mr. O'Rourke. So, Mr. McIntyre, tell me how to read these 
numbers. Since November, El Paso VA has referred 165 veterans 
through Choice and that same time period referred 4,600 
veterans through the PC3 contract. What conclusion should I 
draw, what questions should I be asking related to that?
    Mr. McIntyre. The conclusion you should draw with the 
third-highest volume in our geographic space is that it is 
working. We have gaps in performance. There are differences 
between the two contracts and requirements to providers that 
need to get streamed out, but the fact of the matter is that 
the care that is not accessible in the VA facility in El Paso 
is being delivered downtown. And we are now talking about how 
do we grow the mental health backbone together to make sure 
that we can deliver on that, and that is why I was there 2 
weeks ago.
    Mr. O'Rourke. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much.
    Mr. Gibson, it wasn't too many years ago that Florida 
started a lottery program, and the selling point of the lottery 
program was the funds that would be derived from that program 
would be used to supplement education in Florida. The fear was 
that it wouldn't supplement it, that the base funds would go 
away. Well, that is what has happened.
    Let me assure you there is a $6 billion item already in 
your budget for outside fee care. We are not going to let the 
Choice Program become the lottery funding source for the 
Department of Veterans Affairs. I got the letter. I am checking 
now to see on where some of the money has been diverted, and I 
can assure you that this committee is not going to let the 
Department purposely delete the funds. I just want to make that 
very clear. It was designed to supplement. It wasn't designed 
to replace. And I am not asking for a response. I am just 
making sure you know where we are coming from, and I think you 
already know that.
    But in your testimony today and in letters that you have 
sent to us, you have very cautiously woven in some issues that 
are more management issues than they are budgetary issues. And 
we will reach a conclusion, may not be the one you like, but we 
are all going to make sure that the veterans get to use the 
Choice Program in a way that it was intended so that it is 
successful.
    Mr. Coffman, you are recognized----
    Ms. Brown. Mr. Chairman.
    The Chairman [continuing]. But you cannot use the word 
``Denver'' one time.
    Mr. Coffman. Aurora, Mr. Chairman, Aurora.
    The Chairman. Okay.
    Mr. Coffman. Thank you.
    Ms. Brown. I had a question.
    Mr. Coffman. Thank you, Mr. Chairman. We won't talk about 
that construction project today.
    But let me just say, in Colorado, 9NEWS, one of our local 
TV stations, did an analysis over the first 4 months and found 
that there were only 403 veteran Choice appointments scheduled 
while there were 183,000 appointments scheduled through the VA 
system. It seems like that there is underutilization, and what 
can we do? And I think you have expressed some things today.
    But let me go on to another one because maybe you have 
addressed that, but you can elaborate on that. There is a 
neurologist, a physician, actually a surgeon that I met with in 
Colorado who does the followup work on this. When people have 
Parkinson's, there is a procedure whereby there is I think deep 
brain stimulation to try and stabilize them. And they are 
having to go to San Francisco for that procedure from Colorado 
where we can do it in Colorado.
    Under your new definition of the 40 miles, will veterans 
have the option of staying in Colorado to get that treatment 
with a provider that is reimbursed under the Medicare rate, or 
will they have to go to San Francisco to get that procedure 
done?
    Mr. Gibson. I am going to give you a very honest and direct 
answer: I don't know. The easy answer would just be for me to 
say yes. I think I know the procedure that you are describing.
    Mr. Coffman. Right.
    Mr. Gibson. I have been to San Francisco. I have seen the 
impact that that has. It is a very, very specialized procedure 
and one that we have developed some exceptional in-depth 
experience with. At a clinical level, I think that is part of 
where that decision winds up being made. If we are looking at 
the individual patient acknowledging the hardship of travel, 
looking at the ability to deliver comparable care in the 
community, then I suspect that is one where we would look at it 
and say that is a hardship to travel that far for that 
treatment and therefore we ought to do it here locally.
    On the other hand, if we saw material differences in 
relation to that specific veteran and the capability, the 
relevant capability, we might look and say we think it is 
better for this veteran to be able to make that trip. That is 
an honest answer.
    Mr. Coffman. Mr. Secretary, Deputy Secretary Sloan Gibson, 
9NEWS again did a story about a veteran who had to go to 
Albuquerque, New Mexico, a 200-mile trip, to get--let's see, he 
didn't. So it is $160 worth of travel expenses that he was 
reimbursed and it was for an x-ray he needed that the cost of 
which was evaluated at $160, at least by the investigative 
reporter. I mean, when we talk about the cost, how are we 
rationalizing that?
    Mr. Gibson. That is a perfect example of where we have got 
to use common sense. It makes absolutely no sense, first of 
all, for the hardship on the veteran to make a trip of 150 
miles or whatever it was to get an x-ray. For heaven's sakes, 
that is just not thinking straight. And being able to provide 
the kind of flexibility and set the context inside the 
organization to make those kinds of decisions locally I think 
is where we wind up taking better care of veterans and, 
frankly, doing the better thing for taxpayers.
    Mr. Coffman. Okay. Going back to the issue about the 
extraordinary travel expenses to send somebody from Colorado to 
San Francisco to get a procedure, so it is your view that if 
there is no qualitative difference in terms of offering the 
procedure in terms of cost savings, that it ought to be done 
under the Choice Program in Colorado. Am I correct in that?
    Mr. Gibson. You know, the guideline that I hope, and part 
of what Bob and I both are trying to do, and this is a 
challenge culturally inside the organization, is move us to 
more principle-based approach to making decisions instead of 
rules-based. And so what I would like is that person on the 
ground looking and saying: What is the right thing for veterans 
and the best thing for taxpayers here. And if that means having 
the veteran stay there in Colorado, then that is the decision 
that we ought to be making.
    Mr. Coffman. And let me just follow up very quickly. They 
are also being sent to San Francisco to do routine things in 
terms of followup such as periodically, I guess, these, when 
they do the deep brain stimulation, the batteries have to be 
changed out. I don't know the medical lexicon associated with 
that. But they are going to San Francisco for that, and it 
seems like the followup care certainly could be done in the 
State of Colorado.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you.
    Ms. Rice.
    Ms. Rice. Thank you, Mr. Chairman.
    Mr. McIntyre, Ms. Titus asked a question specifically about 
treatment for women. The question I have is that you suggest 
review of the 60-day authorization limitation?
    Mr. McIntyre. Yes, ma'am.
    Ms. Rice. So you gave two examples of a situation that I am 
sure we do not want veterans--really, who would want to have to 
go through that kind of midstream change in terms of treatment 
when you are talking about serious health issues. So can you 
just expound on that a little bit more and how you would fix 
that?
    Mr. McIntyre. Well, I think the fix is probably going to 
have to be made by all of you, at least from the standpoint of 
giving us the flexibility that doesn't currently exist in the 
law. The way the Choice law was drafted was designed to make 
sure that there was appropriate utilization, not 
overutilization, and in the drafting of that, there was a 60-
day limitation put on how long an authorization for care could 
be.
    So if you are a person who has cancer, you are probably 
getting care for more than 60 days. If you are a person who is 
pregnant, you are probably getting care for more than 60 days. 
If you are a person that is going through radiation oncology, 
you are probably getting care for more than 60 days. And I 
could go on and on as a nonclinician.
    And your position is not unique, and that is that that 
doesn't make a lot of sense. And so I think stepping back, all 
of us, you, the VA, ourselves, to try and figure out what is 
clinically rational and what adjustments are made in order to 
make that work.
    Ms. Rice. So what would the solution be?
    Mr. McIntyre. Because today what happens is, if we receive 
someone to deliver care, then we contact a provider, we send 
them the request for an appointment, we send the authorization 
along with that request for an appointment and all the rules 
that they have to follow, and then they get that person for 
care. And 60 days later they have to present them back to us, 
we have to go back to the VA, under the current rules, to make 
sure that it is okay to continue to deliver care in the 
community.
    As Secretary Gibson said, it is not rational and it doesn't 
make any sense. And so I think we just need to lean forward and 
figure out how to adjust that. We are certainly willing to do 
our part when you do your part.
    Ms. Rice. Well, tell me what our part is.
    Mr. McIntyre. It would be adjusting the requirement.
    Ms. Rice. So it is a language adjustment.
    Mr. McIntyre. It is a language adjustment. And Dr. 
Tuchschmidt might even have thought about this as a clinician 
in terms of what is needed.
    Dr. Tuchschmidt. Yes. So we totally support this change. 
There are a number of changes that I think we are prepared to 
come forward with here shortly asking for changes in the way 
the Choice Program works. One of these is the 60-day 
authorization, and I think the issue is clear about continuity 
of care beyond the 60-day period.
    So what normally happens in the industry, quite frankly, is 
that there is an authorization for an episode of care as 
opposed to 60 days. So that episode of care, if you are being 
referred to an obstetrician for your prenatal care and 
delivery, obviously is not a 60-day episode of care. It is a 
much longer period of time. If it is for the radiation therapy, 
it is for a course of therapy, it is not for 60 days.
    And so I think what we would like to see happen is that 
that 60-day window, quite frankly, just get taken out and that 
we manage this by authorizing episodes of care and using, quite 
frankly, industry standard utilization management criteria that 
we use internally and that we have provided to the TPAs.
    Ms. Rice. Okay.
    Deputy Secretary Gibson, just one question. So we can hear 
individual stories that some of us might hear from constituents 
of ours, and they are very compelling, but those, 
unfortunately, seem too few and far between. Seems to me like 
the veterans service organizations might actually be privy to 
more stories that might be more instructive as to how you 
address a persistent problem.
    So does the VA regularly and have you been--I think I know 
the answer to this--reaching out to the VSOs to ensure that we 
are not waiting just to get into a situation like this to hear 
about the horrible story of a handful of people.
    Mr. Gibson. We are at various levels in the organization, 
from Bob McDonald and I, all the way down to folks in medical 
centers, are regularly meeting with VSOs. I think I am partly 
responsible for Bob's cholesterol level back there because we 
have breakfast together as often as we do. So it is, yes, we do 
that very closely.
    As we do things with Choice, for example, the original 
letter that we sent out, before we sent it out, we gave it to 
the VSOs to get feedback. We are getting ready to send another 
mailer out. We got great feedback from the VSO on things to 
address and things to fine-tune that they are hearing from 
their members aren't clearly communicated. So that is a routine 
part of our approach.
    Ms. Rice. Great. Thank you all very much.
    Mr. Gibson. Yes, ma'am.
    Ms. Rice. I yield back, Mr. Chairman. Thank you.
    The Chairman. Thank you.
    Dr. Wenstrup, you are recognized.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    I appreciate all of you taking on these very complicated 
issues, but I do think that with a lot of perseverance, we have 
a chance to do some great things here.
    First question I have, Mr. McIntyre, do you know offhand 
what, say, the top five physician services are that are being 
referred out?
    Mr. McIntyre. Through Choice?
    Dr. Wenstrup. Yes.
    Mr. McIntyre. It would be physical therapy.
    Dr. Wenstrup. Physician. Physician.
    Mr. McIntyre. Physician services?
    Dr. Wenstrup. Yes.
    Mr. McIntyre. It would depend on market, and it would 
depend on what is the gap at the VA market by market by market.
    Dr. Wenstrup. I guess I was looking for more what your----
    Mr. McIntyre. The average? The Secretary may be able to 
answer that.
    Mr. Gibson. I think primary care is the biggest item.
    Dr. Tuchschmidt. Yes.
    Mr. Gibson. By far.
    Dr. Wenstrup. At some point for the record, if you could 
give me what you think are the top 5 or 10.
    Mr. Gibson. We can give you that breakdown.
    The other thing that I think we are going to see over a 
period of time is those referrals into primary care oftentimes 
are going to lead to a specialty care.
    Dr. Wenstrup. Another referral.
    Mr. Gibson. And so while we see primary care up here right 
now, primary care may move down as some of the other 
specialties move up.
    Dr. Wenstrup. That makes sense to me, especially if you 
have more primary care doctors at the VA, they would refer 
directly to a specialist rather than the other way around.
    So at TriWest, you manage claims and payment, correct?
    Mr. McIntyre. Yes, sir.
    Dr. Wenstrup. Okay. But the administrative rules and 
requirements are set by the VA?
    Mr. McIntyre. Correct.
    Dr. Wenstrup. As far as paperwork?
    Mr. McIntyre. Correct.
    Dr. Wenstrup. Okay. So who does the non-VA provider get 
their check from? Do they get it from TriWest or they it from 
the VA?
    Mr. McIntyre. We pay the provider after the provider 
returns the medical documentation of the encounter to us so 
that the VA can put it in the consolidated medical record for 
the veteran. And then the VA pays us
    Dr. Wenstrup. So you pay them before the VA pays you?
    Mr. McIntyre. Correct. And on average, we are now doing 
that in 30 days.
    Dr. Wenstrup. Okay. Very helpful.
    Now, how does that system compare to other networks that 
you might be managing as far as the paperwork? That is my key 
issue. Because one of the complaints is the VA paperwork is so 
much tougher, so it deters some docs from wanting to be 
providers.
    Mr. McIntyre. You know, there are some requirements that 
are a bit more extensive than they might be under other 
programs. Probably the biggest challenge that we have is that 
there is a different set of requirements for PC3, which 
predated Choice, and for Choice itself, and the need to 
harmonize those two things is pretty important, both for the 
provider, for the provider's staff, for the veteran, for our 
staff, and also for the VA staff.
    Dr. Wenstrup. Because we are looking for ways that can 
streamline things that aren't necessarily related to care and 
get people taken care of, and so it sounds like there is some 
room for improvement there that we can work on, and I 
appreciate that.
    Is there a capability for a non-VA doctor to directly 
contract with the VA?
    Mr. McIntyre. The way it works is that to the degree that 
we don't have a network provider available--and we have 100,000 
now in our network, we will probably have somewhere between 
125,000 to 130,000 when we are done tailoring networks--if we 
can't meet that need that way, then we have a responsibility, 
based on the instructions that you gave to all of us, to go and 
seek a provider in the community that would be willing to serve 
that veteran. So if there is one in a market, we still have a 
responsibility.
    Dr. Wenstrup. Great.
    Mr. McIntyre. Secondly, if the person walks in with an 
individual provider's name, that is the place we start.
    Dr. Wenstrup. Has the SGR fix been helpful in recruitment, 
considering that it is Medicare rates and now there is some 
stability to the Medicare rate?
    Mr. McIntyre. We have been fairly successful in recruiting 
providers. The other side of it is that we are now opening up 
the aperture and allowing providers across our geographic 
expanse to actually identify that they are interested in taking 
care of veterans under Choice at the Medicare rate.
    Dr. Wenstrup. One of the things that I wanted to ask you, 
Mr. Gibson, you mentioned about RVUs increasing. Do you think 
that is because of increased productivity or better 
documentation in increasing the RVUs or a combination?
    Mr. Gibson. I think it is probably a combination. We have 
been increasing our focus on productivity. We have built some 
internal tools to help us do that. That is part of the overall 
discipline that we are trying to impose on the organization. 
Once you start focussing on something, you are probably getting 
better reporting. But when you look at the increase in 
completed appointments, you realize that there is more work 
being completed here.
    Dr. Wenstrup. At some point--I am about out of time--but I 
would like to address further what we are spending, the total 
cost per RVU in our system, and I know we have talked about 
that before.
    Mr. Chairman, I yield back
    The Chairman. Ms. Brownley, you are recognized
    Ms. Brownley. Thank you, Mr. Chairman.
    Mr. Secretary, I think we all know that there is a 
difference in reimbursement rates between the fee basis care, 
the PC3, and the Choice Act. We know that. And you had 
mentioned in your testimony that it is somewhat problematic 
with regards to the Choice Act. And it is true that Choice is 
the least of the reimbursements to providers of those three 
programs. It is not the least?
    Mr. Gibson. PC3 is actually typically negotiated at below 
Medicare rates.
    Ms. Brownley. PC3 is.
    Mr. Gibson. It is, yes.
    Ms. Brownley. Okay.
    Mr. Gibson. So you have got individual authorizations or 
other contracts that may be at Medicare or may be a little 
above Medicare, PC3 below, and then Choice at Medicare. And 
obviously you can surmise the signals that is sending to the 
provider community.
    Ms. Brownley. Well, that is what I was trying to kind of 
drill down a little bit more and following up on Dr. Wenstrup. 
If the Medi-Cal or Medicare rate is less, then is that going to 
drive in terms of having the providers that we need to access 
the program?
    Mr. Gibson. One of the challenges that we are going to have 
as we move to that single network and I think we become 
predominantly Medicare based is, particularly in rural markets, 
our ability to attract providers in rural and highly rural 
markets at Medicare rates. That I expect will be a challenge. 
We know that is a difficulty already because we already 
experience that in our other VA care, and that will be one of 
the areas where I think ultimately we are looking for some 
modicum of flexibility.
    Ms. Brownley. Very good. I think it was you that mentioned 
some of the positive impacts on the Choice Act or what we have 
done is to extend office hours at various facilities. I know in 
my district our veterans are screaming for extended hours with 
our CBOC and we haven't accomplished that. So I am just 
wondering if you have some kind of data to show where we are 
providing those extended hours and where we are not.
    Mr. Gibson. As a matter of fact, we have got very detailed 
data all the way down at least to the medical center level. I 
don't know if I have got it all the way down to the CBOC level. 
When you look at the last year, we are up slightly over 10 
percent in total extended hours, 2 years we are actually up 
almost 27 percent in extended hours care. So it is really one 
of the things that we are trying to emphasize, but we can focus 
on the specific outpatient clinic that you are referring to.
    Ms. Brownley. Well, that would be great. And I am just 
interested in what the VA is doing to continue to drive that 
to. I mean, the goal would be that wherever it is needed, and 
maybe it is not needed everywhere, but wherever it is needed, 
that we do have those extended hours.
    Mr. Gibson. Yes, ma'am.
    Ms. Brownley. And then last. We provide, I think, in terms 
of the wait time data and number of appointments for VA care, 
we have those statistics and it is given to us on a pretty 
regular basis. In your comments you talk about Phoenix and 
Denver and Fayetteville, you mentioned those. But I am 
wondering if you have consistent data for all of the facilities 
across the country for the Choice Act in terms of how we are 
doing. It is very hard to measure. We get a lot of this 
anecdotal feedback, but it is really hard to actually know how 
we are doing center by center by center.
    Mr. Gibson. In fact, we do have that detailed data down to 
the facility level for Choice. As you might expect, it is still 
a very small fraction of the total activity. And so part of our 
challenge is really what we are in the process now is basically 
diverting. Folks are used to doing business the way they do.
    First of all, veterans are confused by this, providers are 
confused by this, and our internal staff are used to doing care 
in the community the way they have always done care in the 
community. Notwithstanding communication and hours of training 
and everything else, we still have people that are ingrained in 
their old habits. And so what we are in the process of doing 
right now is shifting that over.
    We are looking at access writ large and assessing how we 
are improving access and then underneath that how we are using 
the different tools that we have, VA community care being one 
of those broadly and Choice being a part of that. Choice has 
got to become a dramatically larger segment of that care in the 
community that we are delivering.
    Ms. Brownley. And I heard what the chairman said with 
regards to your concept of trying to merge all of these 
programs. If we were going to do that, is the tool that you 
need is simply budget flexibility or does it go beyond that?
    Mr. Gibson. I think ultimately it likely would involve some 
kind of budget flexibility because right now we have got two 
different buckets of money. But I am just presuming that there 
would be other legislative relief that we would need in the 
process of trying to consolidate what are today six or seven 
different channels through which we provide care in the 
community.
    Ms. Brownley. So the Choice Act being underprescribed, what 
is being overprescribed in terms of your budget?
    Mr. Gibson. I would say our traditional VA care. PC3, it is 
still a new program, and it is still a very small percentage. 
It is really our traditional. As I mentioned in my statement, 
we have been referring veterans for care in the community for 
years. Folks are used to doing that a certain way. There are 
providers that they are used to referring their patients to on 
a routine kind of basis. And so that is what is being 
overutilized.
    The requests that the chairman was alluding to earlier was 
really one where from our perspective Choice was designed to 
help accelerate access to care, to make care in the community 
more available to veterans. That is precisely what we have been 
trying to do. We have just been using traditional channels to 
accomplish that as opposed to being able to get all the system 
and veterans and providers in place to do it through Choice.
    Ms. Brownley. Thank you.
    I yield back, Mr. Chairman
    The Chairman. Dr. Abraham.
    Mr. Abraham. Thank you, Mr. Chairman.
    Mr. Secretary, going back to Dr. Roe's line of questioning 
on what you described as the slow----
    Mr. Gibson. Paying low and slow. That is you say down 
South.
    Mr. Abraham. I would add no pay in certain districts in 
Louisiana that I am familiar with. And you said you have had 42 
percent increase in claims. We understand that. And I 
understand that you are trying to consolidate the payment 
system. But objective data, since we have done this, I mean, we 
have got clinics in my district that are owed well over $1 
million, and they have, unfortunately, to their chagrin, turned 
veterans away, not that they want to, but they just can't 
afford to see them. What is the time now as to payment of that 
claim?
    Mr. Gibson. Great. Thanks for the question.
    What VA historically tried to manage to was to pay 80 
percent of claims within 30 days.
    Mr. Abraham. But that is not happening.
    Mr. Gibson. Historically, that happened in most VISNs, but 
VISN 16 was one that chronically underperformed, because I used 
to have the VISN director in my office repeatedly before she 
retired and before we consolidated all this stuff about that 
very issue. In part because of the feedback that we have 
received from you and other Members in the Louisiana 
delegation, we have focused very intensively on VISN 16 and 
specifically on the Louisiana market.
    I can tell you in VISN 16, that 80 percent standard that I 
was referring to, in the month of December in VISN 16, 35 
percent of claims were within 30 days.
    Mr. Abraham. Okay.
    Mr. Gibson. Today that number, I think it is 78 percent are 
within 30 days.
    Mr. Abraham. Okay
    Mr. Gibson. In New Orleans per se it is now at 85 percent, 
still not where it needs to be.
    The other thing I would mention very quickly is, and this 
is part of bringing management focus at an enterprise level to 
this activity, you never would have organized this way to do 
this kind of work ever. It is crazy.
    We are now focussing on issues, and one of the things we 
learned is that the industry standard is actually 90 days, 90 
percent within 30 days, but it is on clean claims. So my 
question was, so what percent of our claims are clean? Sixty. 
Forty percent of our claims don't have authorizations matched 
up with them. That then sends us back into process improvement, 
to figure out how we drive process improvement so that we have 
got a higher percentage of the claims coming in the door that 
are clean so that we can process those timely. We are after it.
    Mr. Abraham. Okay. It sounds like we are making some 
progress.
    Mr. Gibson. We are after it.
    Mr. Abraham. Quick question on Hep C.
    Mr. Gibson. Yes, sir.
    Mr. Abraham. Certainly, ethically and morally, as a 
physician, I know it is much better to treat the disease than 
the symptom.
    Mr. Gibson. Yes, sir.
    Mr. Abraham. And certainly it is more financially 
advantageous to treat the disease, certainly when you are 
talking about a Hepatitis C patient.
    You said there were $660 million shifted to the Hep C 
program. I guess my first question is, where did that money 
come from? And secondly, how much more money are we talking 
about knowing, if you do know to date, how many veterans are 
testing positive for Hep C, and how much money are you 
anticipating, more than the $660 million, needing?
    Mr. Gibson. Yes. We moved $688 million. We moved it from VA 
care in the community because we expected VA care in the 
community to be shifting those costs to over into Choice. That 
hasn't happened, as we have described.
    At the current rate of new starts for Hep C between now and 
the end of the year, we will need $400 million in order to be 
able to close that gap at the current rate. And that is an 
urgent issue for us.
    I think the intermediate-term discussion really has to do 
with what is the requirement that we all, Congress and VA, 
agree that we will manage to. We have today in our records 
136,000 Hepatitis C Active veterans and some additional amount 
that we expect are Hep C positive that aren't in the inventory.
    I think, frankly, the requirement we should be managing to 
is to reach functional zero among veterans that are Hep C 
positive by the end of fiscal year 2018. And I think then you 
step back, you look at the cost associated with doing that over 
a 3-year period of time. But that to me is the discussion that 
we should be having among ourselves, agree on the requirement, 
and then it is basically we are into executing.
    Because the challenge that we run into is you pick a dollar 
amount and you wind up in a situation where you are denying a 
veteran, who is Hep C positive, who comes to see you, he is 
ready for treatment, he is not abusing alcohol, he is not 
abusing substances, and he wants the treatment. And if you have 
managed to a number, you can't provide it. I don't want to put 
our clinicians in that position. You wouldn't want to be in 
that position.
    Mr. Abraham. Right. Okay.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Ms. Kuster.
    Ms. Kuster. Thank you, Mr. Chairman.
    And thank you to our panel.
    I want to follow up on a visit that I had last week to 
White River Junction Hospital in Vermont serving most of my 
district in New Hampshire. First of all, things are going well. 
I was very, very impressed, particularly with the mental 
healthcare. I had a tour of a really outstanding drug and 
alcohol treatment facility that I wish we could have for my 
constituents across the district. And I am pleased to see our 
veterans getting good care. I had a presentation on 
telemedicine that was fascinating and is very helpful.
    What I learned from the folks there is that they actually 
have a preference for the way they were doing business, and I 
think you just made a reference to this. They were providing 
community care as they saw the need, both travel and the 
appropriateness of care in the community.
    And one of the issues that we talked about that was 
preferable under the previous program was the medical record 
and the relationship between the provider at the VA and the 
community provider where the VA was personally engaged in 
setting up that care. They were able to make a call the day 
before the appointment to make sure that the vet received the 
care. They made a followup call, how did it go, do you have any 
questions, is there anything you need from us. They got the 
record electronically in a way that was timely, and so that 
when they came for their next visit at the VA, the VA was aware 
of the care that they had had.
    And so I am happy to work with you. I think, in a 
bipartisan way, there are folks that want to work with you to 
make this work. But that is my question, is how can we do 
better on the transfer of the medical record and, again, just 
being veteran focused to make sure they get the care they need?
    Dr. Tuchschmidt. I am glad to hear that story because that 
is a really exciting good news story I think there.
    I think we have a lot of work to do. We have been 
traditionally a closed kind of HMO model, much like a Kaiser 
Permanente, where we can coordinate care, we can coordinate 
some of those handoffs. And if you look, we have bought more 
and more care out in the community over--well, really going 
back since about 2006, 2007, with this year turning out to be 
probably a banner year.
    The challenge we now have is doing what I think you are 
talking about, is how do we really, if we are getting care 
outside the system and we have more of an open system, how do 
we really coordinate that care and manage that care on behalf 
of veterans, and how do we empower veterans with the right 
information and tools to make wiser decisions for themselves in 
that environment?
    I think we have a lot to learn, quite frankly. I think all 
of American healthcare is trying to figure out how to do this. 
We have a lot to learn. I think that we have really good 
partners to try and do this. And Dave may want to talk about 
some of the new portal stuff that you are opening up.
    But I think ultimately it is about communicating back and 
forth with us: How do we exchange information without having to 
fax and Xerox and all that other kind of stuff and use more of 
an electronic environment?
    Ms. Kuster. Great.
    Mr. McIntyre. One of the gaps that we discovered in Phoenix 
as we and the VA got together to evaluate what went well and 
what didn't go well as we moved through August 17 was that the 
pipes that we had set up didn't allow for the efficient 
movement of information or the effective movement of 
information.
    So prior to that time most of the medical records from the 
community care were not getting back to the VA even though they 
were buying the care directly. One of our obligations and 
Health Net's obligations was to actually make sure that that 
happens. We built it in before we pay the provider. So there is 
an incentive to return it. So we got a lot of this back. It 
went into a portal. And what we discovered was that the VA 
staff found a very labor-intensive process that did not work.
    So we and they sat together in a room with a black belt 
group that actually helped them redesign what those tools were 
going to look like. We are rolling those out starting the 26th 
of May, right after Memorial Day. And so we are revamping the 
entire process, and every geographic space we are responsible 
for will now get a rearchitected approach to how that works.
    Dr. Tuchschmidt. And just in 10 more seconds, I think 
ultimately the ideal situation is if we had computable data 
moving back and forth, if we had the ability to exchange 
information between electronic record systems in the private 
community with our system. I think the state of the art across 
American healthcare is just not there yet to do that in a 
consistent and reliable way.
    Ms. Kuster. Well, from what we have heard in this 
committee, it can't be any harder than trying to exchange it 
with DoD. So thank you very much.
    Thank you, Mr. Chair. I yield back.
    The Chairman. Mr. Costello.
    Mr. Costello. Thank you, Mr. Chairman.
    We are here to talk about the Choice Act, and obviously 
attendant with the Choice Act is making sure that there is 
accountability with the Choice Act. So Deputy Secretary Gibson, 
I want to ask you this question. According to an April 22, 
2015, report, reported in the New York Times, the VA has not 
successfully fired anyone at all for wait time manipulation, 
which continues to be a source of frustration for many. Is it 
too hard to fire VA employees who have committed wrongdoing?
    Mr. Gibson. As I come into this organization from the 
private sector, what I find is it is hard to hire and it is 
hard to fire, and I think that is the case all across the 
Federal Government. I would tell you that we use, have used and 
continue to use every authority that we have at our disposal to 
be able to hold people accountable. But as we take actions, 
those actions, by law, have to be able to withstand an appeal.
    Mr. Costello. So mindful that there were 110 VA medical 
facilities who have maintained secret lists, what you are 
saying is that the actions that are ongoing within the VA are 
intended to root out those who have committed intentional 
wrongdoing relative to data manipulation?
    Mr. Gibson. Yes. There were actually 113 sites that were 
flagged.
    Mr. Costello. Very good.
    Mr. Gibson. And when they were flagged, it didn't mean that 
there was wrongdoing. It meant that there was something in the 
data in the survey that raised a question. A very large number 
of those were ultimately cleared by the IG, and we send a 
letter, a bill of clean health to those organizations so that 
they and their congressional delegation can become aware of 
that.
    Others, the IG comes back with some questions, and we send 
in an investigative team where there are those particular 
questions, and there have been individuals where accountability 
actions have been taken, everything from a letter of reprimand 
up to removal. It is a relatively small number. There are 
dozens of additional of those that are either still with the IG 
or are still in the process of being investigated internally, 
and we are going to continue to pursue it until we have gotten 
through every single one of them.
    Mr. Costello. Let me direct your focus now to AIBs. Now, 
the Philly VARO serves about 800,000 veterans, including some 
in my congressional district. The IG report came out. Now, they 
have impaneled an AIB to more closely scrutinize it and I hope 
name names and start restoring some accountability to identify 
who did wrongdoing.
    There have been AIBs appointed in a number of different--we 
can go to Denver, Wisconsin, Virginia--in instances where the 
AIB has not operated as effectively as it should, I am going to 
put it kindly. How do we go about explaining how those mistakes 
occurred? Do you think the AIB process is inherently flawed? 
How do we make sure that moving forward the AIBs are performing 
at a high level with the expertise needed and with the 
independence needed to make sure that when findings are made 
there are no concerns that things are still being swept under 
the rug?
    Mr. Gibson. Yes. That is a great question. That was and 
still is a fundamental concern that I had in my earliest time, 
in my time as the acting secretary.
    Mr. Costello. And does that still persist?
    Mr. Gibson. That is why I set up the Office of 
Accountability Review. My perception is that VA was in the 
habit of not exercising appropriate accountability actions in 
the wake of mismanagement or wrongdoing. That is a 
generalization, but it was one that I held and still believe 
generally that that had been the case in the organization.
    We set up the Office of Accountability Review in order to 
create that level of independence as part of recalibrating the 
organization's accountability action. So every senior executive 
investigation, every senior leader investigation, and those 
that are of particular note wind up being managed by the Office 
of Accountability Review. They appoint the AIB. And on any 
senior executive issue I am the deciding official. That is how 
I ensure that we are taking appropriate action in relation to 
the misconduct.
    Mr. Costello. To the appointment of the AIB or to the AIB's 
findings?
    Mr. Gibson. The Office of Accountability Review appoints 
the AIB and we ensure that we have got individuals that are 
independent of the organization where the alleged activity has 
occurred. The Office of Accountability Review charges that AIB. 
And on a senior executive, I am the deciding official to 
ensure----
    Mr. Costello. So if an AIB is with a broad brush doing an 
investigation and as part of that investigation you have senior 
officials that may be the subject of inquiry, you are signing 
off on it to make sure that you have the expertise and the 
independence sufficient to do the investigation.
    One final question. Puerto Rico VA, there is a report 
indicating that a potential whistleblower was threatened with 
fines of up to $20,000 for leaking information. Are you 
familiar with this generally?
    Mr. Gibson. I am generally familiar with it, and I have 
directed the Office of Accountability Review to dig in.
    Mr. Costello. And you can appreciate how important it is 
for VA employees across the country to have assurances that 
whomever, if this threat did in fact happen, that it needs to 
be dealt with swiftly because it is the intimidation element 
here that shuts down. In Philly VARO, you have some 
whistleblowers that will not come forward but channel their 
whistleblowing through another whistleblower who is willing to 
step up based on the fear of retaliation.
    Mr. Gibson. Bullying, retaliation, intimidation is 
absolutely unacceptable, and I send that message, Bob sends 
that message every opportunity that we get. The other thing 
that I have messaged across the organization is we will not 
change the culture of VA unless we hold people accountable, and 
that is why this gets as much of my time and attention as it 
does.
    Mr. Costello. Thank you. I yield back.
    The Chairman. Ms. Brown.
    Ms. Brown. Thank you, Mr. Chairman. And before I begin, I 
want to make a couple of quick announcements. First of all, May 
26, the opening of the Orlando VA hospital. Is that correct?
    Mr. Gibson. It is, yes, ma'am.
    Ms. Brown. Okay. Good. So I have heard it here and I am 
going to be down there, so it better open.
    And the next thing is on May 29 is when I am planning on 
going to Denver. So any of the members that would like to go 
with me on the 29th, that is my date, because I really want to 
see the facility and really get a on-hands, in-person update on 
it.
    Mr. Gibson. Yes, ma'am.
    Ms. Brown. So that is May 29.
    And before I just begin my questioning, also I just want 
the chairman to know that I voted for the Florida lottery and 
that was the worst vote I have ever taken in my life, and I 
regret that one.
    Now, on to the questioning. Thank you, Ms. Hoffmeier, for 
coming to Jacksonville. I thought that was extremely helpful. 
Not only did we meet with the veterans, but we also met with 
the stakeholders and various community leaders and 
organizations to get a clear understanding of the Choice 
Program.
    Some of the veterans were saying that the program wasn't 
working. Well, the program just started. And one of the things 
that we in Congress demanded, that we sent a Choice card to all 
of the veterans, whether they was eligible or not. And so that 
created some confusion. And can you address that first? Both of 
you.
    Ms. Hoffmeier. Thank you again, Ms. Brown, for the 
opportunity to attend the meetings with you in Jacksonville. 
They were invaluable.
    I think there is no question that there has been a lot of 
confusion created by the card. Actually, we heard that, as you 
just said, firsthand at the meeting and that was probably one 
of the most helpful discussion points with veterans after the 
meeting.
    I was asked yesterday a question at the Senate VA Committee 
hearing that, to be honest with you, threw me a little bit at 
first but it was whether I had any credits cards. And the 
reason that was asked was because with a credit card you 
receive, about a four-page set of rules in teeny, tiny print 
once a year, and what do most people do with that? 
Unfortunately, they throw it out. It is too hard to read.
    And one of the things that we worked very collaboratively 
with VA on at the beginning in mailing the cards out was trying 
to make sure we designed the envelopes and the letters so it 
was very clear it was official mail and that a veteran would 
read it. But that may not have been the case in every case. And 
I think one of the things that we need to continue to do 
together is to try to make it very easy for veterans to 
understand the program, and we need to do more outreach and 
more education, and really would welcome more opportunities 
like the one we had in Jacksonville with you. So thank you for 
that.
    Ms. Brown. Thank you.
    Dr. Gibson, the article came out in the paper several times 
that my Jacksonville clinic or vet service is one of the worst 
in the country. And so I have had many meetings with veterans. 
And I needed to know the definition of what is the worst in the 
country. And of course, it is not the service at the VA. Once 
they get in there, they think it is the best. It is actually 
getting in there.
    And when we built the clinic, it was already overflowing. 
And that has happened throughout the country because now that 
we have this new awareness, then more veterans are coming 
forward and we have got to figure out how to serve them. And I 
guess it is a little bit of confusion on all of our parts.
    Mr. Gibson. Yes, ma'am. As I alluded to generally in my 
opening statement, what we are finding in instance after 
instance is we take a step, make a major investment to improve 
access to care, and we get a disproportionate response and 
additional demand. That is telling us that there is pent-up 
demand among veterans for additional care at VA. I think 
clearly that was the case in Jacksonville.
    I will tell you, one of my points of frustration. I visited 
Gainesville, Florida, on the 26th of June. It was on that day 
that I directed that the team there, that has responsibility 
for the Jacksonville outpatient clinic, to go find space in the 
community so that we could expand access to care and get 
additional providers. We are hoping--we are hoping--to be able 
to see veterans in that space in August.
    And I am told that that is at light speed as we have worked 
through the acquisition process associated with being able to 
go lease 20,000 square feet of space. And so that is not 
responsive to the needs of veterans.
    I would tell you, it hasn't come up. We are talking about 
Choice, we got 27 leases that were authorized in the Choice 
Act. On average, we are saying right now it is going to take us 
5 years to activate those facilities. That is unacceptable. 
That is not responsive to the needs of veterans.
    We have been doing Lean Six Sigma on that process to try to 
figure out how we accelerate it, and maybe we have trimmed 4 or 
5 months off. That is not acceptable. We have to find a better 
way to do that in order to meet the needs of veterans
    Ms. Brown. What I want to know is what is it that we can 
do. You talked about flexibility. We need to know exactly what 
kind of flexibility that you have had. Because I have talked to 
some of our stakeholders. For example, you said UF Shands, they 
want to be partners. All 400 of their physicians have signed up 
for the Choice Program. I mean, we have a hospital right there, 
right next to it that can provide additional space. And trying 
to get the Choice with the community, the other program that is 
already in place, and what is the difference between the two? I 
mean, why is it that we can't speed it up?
    Mr. Gibson. We will actually be providing specific language 
that support each of the individual requests that I have 
identified in my opening statement, and that includes that kind 
of flexibility that would allow us to be able to utilize Choice 
for a lot of that care.
    Ms. Brown. Last thing. I mean, the Denver issue we are 
discussing and trying to figure out how we are going to come up 
with the flexibility because we don't need to leave Denver 
without the funding source that they need. But many Members 
have said: Well, we don't want to take the money from the 
Choice Program. And I certainly don't want to take it from the 
$5 billion that we have gotten to provide additional 
physicians, additional clinics, or whatever we need.
    And you say: Well, Denver is not my area. Our 
responsibility on this committee is for veterans all over the 
country. And so we have got to work to figure out how we are 
going to meet these extremely challenging areas of----
    Mr. Gibson. Yes, ma'am.
    Ms. Brown [continuing]. Funding these other facilities that 
are almost ready, but the cost overruns. And when we say cost 
overruns, was that a realistic cost in the beginning?
    Mr. Gibson. I think all the evidence indicates that it was 
not.
    Ms. Brown. You got an answer to my question, though?
    Mr. Gibson. Well, the answer is, yes, we have to find a way 
to pay for that. In prior years I would tell you there would 
have been much more flexibility inside VA. We are doing 
everything we can, Hepatitis C, access to care in the 
community, additional hiring, accelerating hiring, trying to 
improve access to care. This is not the time where we can go 
find $700 million sitting on the sidelines somewhere. There are 
no easy answers.
    If we are permitted to access the $5 billion, we will get 
the minor construction programs into the 2017 budget, we will 
work all those nonrecurring maintenance items into the 2017 and 
the 2018 budget to the extent that the budget amount will allow 
us to do that, so that it is not an open-ended delay in those 
particular projects. But we are out of alternatives in terms of 
finding a place to cover that cost.
    Ms. Brown. Well, let me again thank you for your service 
and all of you all for your testimony this morning.
    Mr. Gibson. Yes, ma'am.
    The Chairman. Mr. Lamborn.
    Mr. Lamborn. Thank you for the consideration.
    Mr. McIntyre, before I ask a question of you, I just want 
to say that you used to provide care in Colorado. And I want to 
commend you. You had an excellent reputation, your whole 
organization, and you did an exemplary job. So thank you.
    Mr. McIntyre. Thank you, sir.
    Mr. Lamborn. I know that you pay the providers in your 
network promptly, it sounds like. But my question isn't that, 
but how promptly are you paid by the VA so that you in turn can 
pay the providers in your network?
    Mr. McIntyre. Well, we are paying the providers with our 
funds, and then we seek to gain reimbursement from the VA.
    I would say at this point it is actually working reasonably 
well. And it takes a little while to get the gears moving. You 
have to make sure when you are establishing something new that 
you have stress tested whether the paper that is being 
submitted is worthy of payment. So you have got that issue on 
their side, they have done an appropriate job at that. But we 
have payment streams that are starting to move.
    And I think, based on what we have seen so far, we will hit 
a rhythm. And I am pretty confident that if we face a problem 
in that space, given what we are responsible for, that the 
Deputy Secretary and the team underneath him would be very 
focused because that is what they have demonstrated today.
    Mr. Lamborn. Do you have a timeframe you could give us?
    Mr. McIntyre. Timeframe for?
    Mr. Lamborn. On how quickly you are reimbursed?
    Mr. McIntyre. I could pull some information for you. I 
don't have it at the top of my fingertips.
     We do have a few spaces where we have got some arrears, 
but those things are being attended to. The challenge is that 
some of this has to run through each VA medical center given 
the uniqueness of some of these programs.
    Mr. Lamborn. Okay.
    Mr. McIntyre. We are in good shape.
    Mr. Lamborn. All right. Thank you.
    Now, Mr. Gibson, I am going to ask you about an unrelated 
matter, because I am going to take advantage of the fact that 
you are here in front of us today. So you may not be 100 
percent prepped on this, but I am sure it is something you are 
following.
    Mr. Gibson. I will give it a try.
    Mr. Lamborn. Earlier this week there was an article in the 
Wall Street Journal and it talked about the computerized 
disability assessments. And it said that there was a high error 
rate, because probably in the desire to save time. But anyway, 
the result was there was less human interaction. The reviewer 
wasn't allowed or the program didn't accommodate individual 
comments that may help give a more rounded picture, a more 
complete picture of the disability. So what is your response to 
that article in the Wall Street Journal?
    Mr. Gibson. Since I have been busy preparing and testifying 
these last couple of days, I haven't had the chance to do the 
deep dive on that issue. That is tomorrow. I would tell you, as 
I am recalling, the person that was quoted in the article had 
left VA in 2012, had worked at VA for many years, and I suspect 
the context within which that person had experienced claim 
processing was one of a paper-based process where you had 
individuals sitting and turning every single page.
    Our duty to assist means that the claims raters are 
basically looking at every single piece of evidence that sits 
in that file. Part of what we have done here is gone through a 
paradigm shift in terms of how we operate and harnessing 
automation to be a tool for individuals to be able to make 
well-informed decisions. It is not to take information out of 
their hands, it is to make the information more readily 
available. They still have the obligation to review all the 
evidence in the file when they are making that particular 
decision.
    Now, having said all that, I will do the deep dive starting 
tomorrow so that I can understand more substantively if there 
is a particular part of the VBMS system that this individual 
was making reference to so that I can understand what the 
specifics are.
    Mr. Lamborn. Okay. Thank you. I think everyone would agree, 
we want those assessments to be as accurate as possible.
    Mr. Gibson. Absolutely.
    Mr. Lamborn. Not too low or not too high. I mean, it has to 
be accurate.
    Mr. Gibson. Doing the right thing for veterans and being 
good stewards of taxpayer resources. It is both at the same 
time. And if we are granting disability when there is not an 
entitlement for that, we are not doing the right thing for the 
taxpayer.
    Mr. Lamborn. Mr. Chairman, maybe we can hear more about 
that at one of our future hearings. Thank you, and I yield 
back.
    The Chairman. Thank you very much. We appreciate the first 
panel.
    I would read one thing out of the Choice Act law that says 
that: It is the sense of Congress that the Veterans Choice Fund 
is a supplement but distinct from the Department of Veterans 
Affairs' current and expected level of non-Department care 
currently used by the Department's medical care budget. 
Congress expects that the Department will maintain at least its 
existing obligations of non-Department care programs in 
addition to but distinct from the Veterans Choice Fund for each 
of the fiscal years 2015-2017.
    Mr. Gibson. And I am very familiar with that provision, and 
my interpretation of that language has always been that the 
idea was don't let VA use Choice money instead of using money 
for other care in the community programs and then take and 
divert those funds someplace else. We have done exactly the 
opposite. We have, in effect, overused care in the community.
    The Chairman. I appreciate it very much, but while I agree 
with the desire to manage to requirement, you have a budget, 
and there have been decisions made within that budget that 
busted the budget. You are trying to backfill that budget now 
by extracting from one fund and then talking about using the 
Choice Program as the default program, which sounds great. But 
when you are pulling money out of the other program that was 
supposed to be supplemented it is going to drain the money out 
of the Choice Program much quicker than it was originally 
intended.
    So while I appreciate the magical accounting that your 
folks have figured out, that is not the intent of Congress. And 
we will work with you in the budget on Hep C. I get it. But 
somebody was asleep at the switch on the request. I mean, $100 
million, then it goes to $600 million, that is almost like the 
Aurora hospital at 350 to 1.75. Somebody has got to get better 
at forecasting. And I know you and the Secretary are working 
very diligently----
    Mr. Gibson. We are.
    The Chairman [continuing]. In order to correct that, so 
this is not aimed specifically at you, but maybe to the bean 
counters within the Department that are trying to find the 
dollars. But this is not a place to look.
    And I appreciate very much everybody being here today. We 
have got a second panel to go to. So thank you very much.
    Mr. Abraham. [Presiding.] Appreciate you guys being here.
    Joining us on the second panel is Darin Selnick, Senior 
Veterans Affairs Advisor for the Concerned Veterans for 
America; Carlos Fuentes, Senior Legislative Associate for the 
National Legislative Service of the Veterans of Foreign Wars of 
the United States; Roscoe Butler, the Deputy Director for 
Healthcare for the Veterans Affairs and Rehabilitation Division 
of the American Legion; Joseph Violante, Legislative Director 
for the Disabled American Veterans; and Christopher Neiweem, 
the Legislative Associate for the Iraq and Afghanistan Veterans 
of America.
    Thank you for all being here.
    Mr. Selnick, we will start with you. You have 5 minutes, 
sir.

 STATEMENT OF DARIN SELNICK, SENIOR VETERANS AFFAIRS ADVISOR, 
    CONCERNED VETERANS FOR AMERICA; CARLOS FUENTES, SENIOR 
 LEGISLATIVE ASSOCIATE, NATIONAL LEGISLATIVE SERVICE, VETERANS 
OF FOREIGN WARS OF THE UNITED STATES; ROSCOE G. BUTLER, DEPUTY 
 DIRECTOR FOR HEALTHCARE, VETERANS AFFAIRS AND REHABILITATION 
  DIVISION, THE AMERICAN LEGION; JOSEPH A. VIOLANTE, NATIONAL 
     LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; AND 
     CHRISTOPHER NEIWEEM, LEGISLATIVE ASSOCIATE, IRAQ AND 
                AFGHANISTAN VETERANS OF AMERICA

                   STATEMENT OF DARIN SELNICK

    Mr. Selnick. Chairman Miller, Ranking Member Brown, and 
members of the committee, I appreciate the opportunity to 
testify at today's hearing on the Choice program, and thank you 
for your leadership in ensuring that veterans get the quality 
healthcare they deserve.
    Today, true choice in veterans healthcare remains out of 
reach for most veterans. Like a mirage in the desert, as you 
move closer, it recedes into the horizon.
    Our assessment is that the Choice program has been 
unsuccessful and is not a long-term solution. As such, we have 
developed recommendations for comprehensive reform through the 
bipartisan Fixing Veterans healthcare Task Force. The current 
rules pertaining to Choice do not represent real choice. 
Instead, they require veterans to obtain approval from VA 
before they are able to make a choice. Veterans should not have 
to ask for permission to select their healthcare provider.
    VA implementation of the Choice program has been a failure. 
For example, the Associated Press has reported ``GAO says 
veterans' healthcare costs a high risk for taxpayers.'' The 
number of medical appointments that take longer than 90 days to 
complete has nearly doubled, and that only 37,000 medical 
appointments have been made through April 11.
    Last fall, CVA commissioned a national poll of veterans. 
The result showed 90 percent favored efforts to reform veterans 
healthcare; 88 percent said eligible veterans should be given 
the choice to receive medical care from any source they choose; 
77 percent want more choices, even if it involved higher out-
of-pocket costs.
    Choice and competition are the bedrock of today's 
healthcare system. We choose our healthcare insurance provider 
and primary care physician. healthcare organizations provide 
quality and convenient care because they know if they don't, 
they will lose their patients to someone else. In order to fix 
the VA healthcare system, both choice and competition must be 
injected into the system.
    VA has recognized this when they said, ``Evaluation options 
for potential reorganization that puts the veteran in control 
of how, when, and where they wish to be served. Unfortunately, 
veterans do not have that control, and will not under the 
current VA healthcare system. VA needs a 2015 healthcare 
system. We believe the Veterans Independence Act is a roadmap 
and solution to do just that. This roadmap was developed by the 
Fixing Veterans healthcare Task Force, co-chaired by Dr. Bill 
Frist, former Senate majority leader, Jim Marshall, former 
Congressman from Georgia, Avik Roy of the Manhattan Institute, 
and Dr. Mike Kussman, former VHA Under Secretary.
    We first developed 10 veteran-centric core principles that 
serve as the guiding foundation. These principles included: The 
veteran must come first, not the VA. Veterans should be able to 
choose where to get their healthcare. Refocus on and prioritize 
veterans with service-connected disabilities and specialized 
needs. VA should be improved and thereby preserved. Grandfather 
current enrollees. And VHA needs accountability.
    To implement these principles, we laid out three major 
categories of reform and nine policy recommendations:
    First, restructure the VHA's independent government 
chartered, nonprofit corporation. And power to make decisions 
of personnel, IT, facilities, partnerships, and other 
priorities; second, give veterans the option to seek private 
healthcare coverage with their VA funds; third, re-focus 
veterans healthcare and those service-connected injuries to 
VA's original mission. The key policy recommendations included 
separate the VA's payer and provider functions into separate 
institutions.
    Establish the veterans health insurance program as a 
program office in VHA. Establish the Veterans Accountable Care 
Organization, VACO, as a non-profit government corporation 
fully separate from VA. Preserve the traditional VA health 
benefit for enrollees who prefer it, while offering an option 
to seek coverage from the private sector through three planned 
choices.
    VetsCare Federal. Full access to the VACO integrated 
healthcare system with no changes to benefits or cost sharing. 
VetsCare Choice. Select any private healthcare insurance plan 
legally available in their State financed through premium 
support payments.
    And VetsCare Senior. Medicare eligible veterans can use 
their VA funds to defray the cost of Medicare premiums and 
supplemental coverage. Lastly, create a VetsCare Implementation 
Commission to implement the Veterans Independence Act.
    We retained the services of HSI to conduct the physical 
analysis. HSI determined a properly designed version of these 
policy recommendations is likely to be deficit neutral.
    In order the fix veterans healthcare, we must always keep 
in mind what General Omar Bradley said in 1947. ``We are 
dealing with veterans, not procedures. With their problems, not 
ours.''
    That is why we urge you to use the Veterans Independence 
Act roadmap to develop the legislative blueprint that will 
finally fix veterans' healthcare. Veterans must be assured that 
they will be able to get the quality and convenient healthcare 
they deserve. In this mission, failure is not an option. We are 
committed to overcoming any and all obstacles that stand in the 
way of achieving this important mission. We look forward to 
working with the chairman, ranking member, and all members of 
this committee to achieve this shared mission.
    Thank you.

    [The prepared statement of Mr. Selnick appears in the 
Appendix]

    Mr. Abraham. Thank you, Mr. Selnick.
    Mr. Fuentes.

                  STATEMENT OF CARLOS FUENTES

    Mr. Fuentes. Chairman Abraham and Ranking Member O'Rourke, 
thank you for the opportunity to present the views of the men 
and women of the VFW and our auxiliaries.
    The VFW has continued to play an integral role in 
identifying new issues the Veteran Choice Program faces, and 
recommending reasonable solutions.
    Yesterday we published our second report evaluating this 
important program which made 13 recommendations to ensure that 
the program accomplishes its intended goal of expanding access 
to healthcare for America's veterans.
    Our initial report identified a gap between the number of 
veterans who are eligible for the program and the number of 
veterans who were given the opportunity to participate.
    Our second report found that VA has made progress in 
addressing this issue. Thirty-five percent of second survey 
participants who believed they were eligible were given the 
opportunity to participate. That is a 16 percent increase from 
our initial survey, yet we continue to hear from veterans who 
report that schedulers they speak to are unaware of the program 
or unsure how it works. For 30 day-ers, participation hinges on 
VA staff informing them of their eligibility. The lack of 
system-wide training for frontline staff has resulted in 
veterans receiving dated or misleading information. VA must 
continue to improve its processes and training to ensure all 
veterans who are eligible have the ability to receive 
healthcare in their communities.
    Our second report also validated that veterans are 
satisfied with their VA healthcare experience if they receive 
timely access. 90 percent of survey participants who received 
care within 30 days reported that they were satisfied with 
their VA healthcare experience. Satisfaction dropped to 67 
percent for participants who waited longer than 30 days.
    The 40-mile standard used to establish geographic-based 
eligibility for the Veterans Choice Program does not properly 
account for the diversity of the veterans' population. Thirty-
six percent of veterans enrolled in the VA healthcare system 
live in rural areas. Many of them are required to travel more 
than 40 miles for general goods and services. On the other 
hand, some urban veterans live within 40 miles of a VA medical 
center, but are required to travel several hours for their 
care.
    Our second report found that a commute time standard, based 
on population densities, would more appropriately reflect the 
travel burden veterans face when accessing VA healthcare.
    Section 201 of the Choice Act mandated 12 independent 
assessments of the VA healthcare system. One of those being 
carried out by the Institute of Medicine will evaluate how VA 
measures wait times; however, none of them evaluate the 40-mile 
standard. Congress and VA must commission a study to determine 
what is an appropriate measure for the geographic burden that 
veterans face when traveling to VA medical facilities.
    As the future of the VA healthcare system and its purchased 
care model are evaluated, it is important to recognize that the 
quality of care veterans receive from VA is significantly 
better than what is available in the private sector. Moreover, 
many of the VA capabilities cannot be duplicated or properly 
supplemented by private sector healthcare systems, especially 
for combat-related mental health conditions, blast injuries AND 
service-related toxic exposures, just to name a few. With this 
in mind, VA must continue to serve as the initial touch point 
and guarantor of care for enrolled veterans.
    Although enrollment in the VA healthcare system is not 
mandatory, and despite more than 80 percent of the veterans 
having other forms of healthcare coverage, more than 6.5 
million veterans choose to rely on their earned VA healthcare 
benefits and are, by and large, satisfied with the care they 
receive.
    Moving forward, the lessons learned from the Veterans 
Choice Program should be incorporated into a single systemwide 
non-VA care program with veteran centric and clinically driven 
access standards which afford veterans the option to receive 
care from the private sector if VA is unable to meet those 
standards.
    More importantly, non-VA care must supplement the care 
veterans receive from VA medical facilities, not replace it. 
Ideally, VA would have the capacity to provide timely access to 
direct care to all the veterans it serves. We know, however, 
that VA medical facilities continue to operate at 150 percent 
capacity and may never have the ability to expand care to 
deliver direct care to all the veterans it serves. VA must 
continue to expand capacity based on staffing models for each 
healthcare specialty and patient density thresholds.
    However, VA cannot rely on building new facilities alone. 
When thresholds are exceeded, VA must use leasing and sharing 
agreements with other healthcare systems when possible, and 
purchased care when it must.
    Mr. Chairman, this concludes my testimony. I am prepared to 
take my questions you or the committee members may have.

    [The prepared statement of Mr. Fuentes appears in the 
Appendix]

    Mr. Abraham. Thank you, Mr. Fuentes.
    Mr. Butler, you have 5 minutes.

                 STATEMENT OF ROSCOE G. BUTLER

    Mr. Butler. Chairman Abraham, Ranking Member O'Rourke and 
distinguished members of the committee, on behalf of our 
National Commander Michael Helm and the 2.3 million members of 
the American Legion, we thank you for this opportunity to 
testify regarding the American Legion's views of the progress 
of the Veterans Choice Program.
    The American Legion supported the Veterans Access Choice 
and Accountability Act of 2014 as a means of addressing 
emerging problems within the Department of Veterans Affairs. 
VA's wait times for outpatient medical care had reached an 
unacceptable level nationwide as veterans struggled to receive 
access to timely healthcare within the VA healthcare system. It 
was clear that swift changes were needed to ensure veterans 
could access healthcare in a timely manner. As a result, the 
American Legion immediately took charge by setting up veterans 
benefit centers, or VBCs, in big and small cities across the 
country to assist veterans in need and their families as a 
result of the systemic scheduling crisis facing the VA.
    The American Legion VBC's charge is to work firsthand with 
veterans experiencing difficulties in obtaining healthcare or 
having difficulties in receiving their benefits.
    On November 7, 2014, VA rolled out the Veterans Choice 
Program, and after 6 months, it is clear the program falls 
short of the initial projections from the CBO. According to the 
VA's latest daily Choice metrics dated March 31, 2015, there 
were approximately 51,000 authorizations issued for non-VA care 
since implementation of the Choice program, with about 49,000 
appointments scheduled. When you compare those numbers to the 
over 8 million Choice cards issued, one would ask, why did VA 
issue so many Choice cards?
    Nevertheless, the American Legion is optimistic that the 
recent rule changed by VA eliminating the straight-line rule 
and using the actual driving distance will allow more veterans 
access to healthcare under the Veterans Choice Program. The 
American Legion also believes if VA were to move forward with 
the 40-mile rule change to only include a VA medical facility 
that can provide the needed medical care or services, everyone 
would see increases in utilization and access to non-VA 
healthcare.
    The American Legion applauds the Senate for unanimously 
passing an amendment reminding the Department of Veterans 
Affairs that they have the obligation to provide non-VA care 
when it cannot offer that same treatment at one of its own 
facilities that is within the 40-mile driving distance from the 
veteran's home.
    We now call upon the House to take up H.R. 572, the 
Veterans Access to Choice Care Act, and ensure its swift 
passage. Let's get the bill to the President's desk and make 
sure we are taking care of our rural veterans.
    During a recent visit last month to examine the healthcare 
system in Puerto Rico, the American Legion learned that VA 
staff had been mistakenly telling veterans that no one on the 
island is eligible for healthcare under the Veterans Choice 
Program because there is no medical facility that is further 
than 40 miles from anywhere on the island. The American Legion 
is concerned that as a result of inadequate training, there 
could be staff at many VA healthcare facilities who failed to 
receive proper training as a result, and are communicating 
incorrect information.
    While VA has issued a number of fact sheets and press 
releases, VA has not issued a single national directive and 
supporting handbook which sets forth VHA policy and operational 
procedures on the Choice program. VA failure to issue such 
national policies and procedures and tie them to existing VHA 
policies and procedures contribute to inconsistencies in 
implementation and staff failure to understand key principles 
of the program. Fact sheets and press releases are great, but 
they are not VHA policy and procedures.
    In fiscal year 2014, VA spent $7 billion on national--on 
non-VA care. Many of VA's non-VA care and programs are mandated 
by different program offices and VA central office, and some of 
the programs are handled outside of VA's fee basis claims 
processing systems.
    VA should streamline its current purchased care model to 
incorporate all of non-VA's care programs into a single 
integrated program.
    Thank you again, Mr. Chairman, ranking member. I appreciate 
the opportunity to present The American Legion's views and look 
forward to answer any questions you may have.

    [The prepared statement of Mr. Butler appears in the 
Appendix]

    Mr. Abraham. Thank you, Mr. Butler.
    Mr. Violante.

                STATEMENT OF JOSEPH A. VIOLANTE

    Mr. Violante. Chairman Miller, Ranking Member Brown, and 
members of the committee, on behalf of DAV and our 1.2 million 
members, all of whom were wounded, injured, or made ill from 
their wartime service, thank you for the invitation to testify 
on progress of the temporary Choice program. While it is too 
early to reach definite conclusions about this program, we are 
beginning to see some early lessons. Utilization of Choice 
program is lower than expected, and that can be attributed to a 
number of factors.
    First, since the crisis erupted last spring, VA has used 
every available resource to increase its capacity to provide 
timely care. That probably has shifted some of the demand away 
from Choice.
    Second, VA was slow in rolling out Choice cards and in 
educating its staff, and that confusion continues to discourage 
some veterans today.
    Finally, some veterans simply prefer to use VA.
    Mr. Chairman, we understand that desire to quickly fix the 
Choice program and to overhaul how VA provide care inside the 
system and in the community. But it could be a tragic mistake 
to rush towards permanent, systematic solutions with unknown 
consequences that would gamble with something as important as--
to veterans as VA healthcare system. That is why the Choice Act 
mandated a commission to carefully study and work towards 
consensus recommendations on how best to reform VA.
    Recently, DAV, VFW, the American Legion, IAVA, and other 
VSOs signed a joint letter calling on Congress to give the 
commission enough time to do its job properly. And once the 
commission issues its final report, then allow sufficient 
opportunity for stakeholders in Congress to engage in a debate 
worthy of the men and women who served.
    For more than 150 years, going back to President Lincoln's 
solemn vow ``to care for him who shall have borne the battle,'' 
the VA healthcare system has been the embodiment of our 
National promise. Yet you have heard one proposal today from 
the CVA witness calling for VA to become just another Choice 
among healthcare providers. But if you actually read their 
report and look behind their poll-tested sound bites, you can 
clearly see what they are intending is for VA to be privatized 
and downsized. And under their proposal, VA could even be 
eliminated if that is what the market chooses.
    But for millions of veterans, the most seriously disabled, 
there is only one choice for receiving the specialized care 
they need, and that is a healthy and robust VA. Although VA 
provides comprehensive medical care to more than 6 million 
veterans, VA's primary mission is to meet the unique 
specialized healthcare needs of the Nation's 3.8 million 
service-connected disabled vets. If VA was privatized, 
downsized, or eliminated, as the CVA proposal could lead to, 
would the civilian healthcare system actually be able to 
provide timely access to specialized care that disabled 
veterans require?
    Even if all disabled--service-disabled veterans were 
dispensed in the civilian healthcare system, they would be just 
1.5 percent of the total adult population. Does anyone truly 
believe that a market-based private sector healthcare system 
would provide the focus and resources necessary to ensure the 
highest standards of specialized care for this small minority 
in the same way that VA does?
    Mr. Chairman, we can and must do better for the men and 
women who have sacrificed so much for our freedom.
    In DAV's written testimony, we have outlined a framework 
for how to rebuild, restructure, realign, and reform the VA 
healthcare system. We need to rebuild VA's capacity to provide 
high-quality, patient-centered care, restructure non-VA care 
programs to ensure timely and seamless access, realign VA's 
healthcare services to meet the needs of the next generation of 
veterans, including women veterans, and reform VA's management 
with greater transparency and true accountability.
    Mr. Chairman, this framework is not intended to be a final 
or detailed plan, nor could it be at this point. But it offers 
a pathway forward to a future that would keep the promise 
Lincoln so eloquently laid out.
    That concludes my testimony. I would be happy to answer any 
questions.

    [The prepared statement of Mr. Violante appears in the 
Appendix]

    Mr. Abraham. Thank you, Mr. Violante.
    Mr. Neiweem.

                STATEMENT OF CHRISTOPHER NEIWEEM

    Mr. Neiweem. Thank you, Chairman Abraham, Ranking Member 
O'Rourke, and distinguished members of the committee.
    On behalf of Iraq and Afghanistan Veterans of America and 
our nearly 400,000 members and supporters, thank you for the 
opportunity to share our views with you at today's hearing, 
assessing the promise and progress of the Choice program.
    IAVA was one of the leading veterans organizations involved 
in the early negotiations on the Veterans Access to Choice and 
Accountability Act as it was being drafted and the breadth of 
its final language was debated. This is a highly complex law 
that the Department is continuing to work to effectively 
implement in order to ensure veterans are not left waiting 
unacceptable lengths of time to receive healthcare services.
    My remarks will focus on the experiences of utilizing the 
VA Choice program IAVA members have recently reported by way of 
survey research. Additionally, I will provide recommendations 
Congress and the Secretary must consider in order to get the 
program operating at the height of its potential.
    These recommendations include legislative clarification of 
the eligibility criteria for assessing the Choice program; 
strengthening training guidelines for VA schedulers charged to 
explain the eligibility criteria to veterans; and active 
engagement with veteran organizations to more broadly identify 
a comprehensive strategy and plan for delivering non-VA care in 
the future.
    In examining the current criteria for determining which 
veterans are eligible to use the Choice program, those who must 
wait longer than 30 days for an appointment and those who live 
more than 40 miles from a VA medical facility, more statutory 
clarity is required. Veterans are all too frequently reporting 
they are unsure if they are eligible for Choice, and VA has, in 
some cases, been inconsistent in communicating whether or not a 
veteran can access it in individual cases.
    Over one-third of IAVA members have reported they do not 
know how to access the program. This is compounded by reports 
that, in some case, VA scheduling personnel are not explaining 
eligibility for Choice to veterans and are then offering 
appointments off the grid of the 30-day standards, and 
sometimes, much later. I know because I had experienced it 
myself just last month at the VA medical facility here in DC.
    The Secretary must continue to engage VA front-facing 
scheduling personnel with ongoing and evolving training 
standards so when veterans call the VA, they hang up the phone 
with the correct or best answer that explains their Choice 
eligibility. The VA has improved in this area, but with so many 
veterans still confused about Choice and eligibility nearly 9 
months after the program's birth, training criteria must be 
strengthened and maintained to get it right.
    Congress should aid in the Department's implementation 
efforts by clarifying in law that the 40-mile criteria must 
relate specifically to the VA facility in which the needed 
medical care will be provided.
    The frustrating example that has surfaced is one of a 
veteran that requires specialized care in a VA facility outside 
of 40 miles, but through strict interpretation of current VACAA 
law is ineligible for participation because a local CBOC may be 
geographically near the veteran's address, notwithstanding that 
facility cannot provide the required care.
    One of our members illustrated one of these cases with the 
following statement. ``Because there is a CBOC in my area, I 
was denied. The clinic doesn't provide any service or treatment 
I need for my primary service-connected disability. The nearest 
medical center in my network is 153 miles away.''
    Congress must provide much-needed clarity and work with VA 
to eliminate cases like those just described. However, VA's 
action to step up to fix the initial ineffectiveness of the 40-
mile rule calculations under regulation as it related to 
geodesic distance versus driving distance is encouraging. That 
regulatory correction was much needed, and we applaud the 
Secretary for leading to make that change happen.
    VHA's statistics on Choice utilization among the veteran 
population as of this month state there have been nearly 58,863 
authorizations for care, and nearly 47,000 appointments for 
care. This data verifies that veterans are out and they are 
using the program, and VA is making progress to implement what 
is clearly a complex and historic mandate relating to the 
punishment of veterans healthcare now and in the years to come.
    IAVA is committed to remaining actively engaged with 
veterans making use of Choice care so we can keep current on 
the veteran experience. We are mindful that with thousands of 
appointments for care being concluded, there will inevitably be 
thousands of unique experiences we want to know about to gauge 
the satisfaction that these veterans are having with the 
program. The satisfaction of the veterans utilizing Choice, the 
cost of the care purchased outside of VA facilities, and 
understanding issues that come up along the way will allow us 
to better identify the scope and role of the concept Choice 
plays in the future.
    We appreciate the hard work of Congress, the VA, and the 
veteran community, and recognize we have to stay focused on 
improving veteran healthcare delivery in the short term and 
long term. Robust discussion on the scope and cost of 
maintaining healthcare networks is complicated and multi-
layered, which is why our last recommendation is simple. We 
must continue to work together and keep communication active 
among all relevant stakeholders.
    Mr. Chairman, we sincerely appreciate your committee's hard 
work in this area. We also sincerely appreciate Chairman 
Miller's recently introduced Veterans Accountability Act, which 
we strongly support, your invitation to allow us to participate 
in this important hearing, and we stand ready to assist 
Congress and Secretary Bob McDonald to achieve the best results 
for the Choice program now and in the future, and happy to 
answer any questions you or members of the committee may have.

    [The statement of Mr. Neiweem appears in the Appendix]

    Mr. Abraham. Thank you, Mr. Neiweem.
    I have a question for the entire panel, and I will start 
with you, Mr. Selnick, and we will go down the line.
    There are some serious concerns regarding the training the 
VA and the TPA staff have received during the Choice program. 
Moving forward, what are your recommendations for the VA and 
the TPAs to improve their training efforts for the Choice 
program?
    Mr. Selnick. Yes. Thank you, Mr. Chairman, for that 
question.
    I used to work at the VA, and when I was at the VA for 
several years, I headed up the VA Learning University, which 
was the department-wide--first-ever department-wide education 
training. We did the first-ever strategic plan for VA.
    VA has never fully implemented that strategic plan, and it 
strategically changed where it located its department-wide 
training over at HR. And so one of the problems is this whole 
training mechanism is faulty and does not work well.
    I know they have been trying to improve that, but VHA has 
always had a poor record in terms of overall training 
developments and a lack of ability to go ahead and be flexible 
in terms of the way it does its training. Having worked at a 
number of healthcare organizations and understanding how 
important the flexibility and the ability to change your 
training and update your training as needed as new situations 
come, VHA just does not have the inherent capability to do it. 
It needs to revitalize and update its strategic plan, and it 
needs to develop the flexibilities in concert with its EES, the 
VHA training system in concert with VA--to be able to take care 
of flex needs such as the Choice program.
    Mr. Abraham. Mr. Fuentes.
    Thank you, Mr. Selnick.
    Mr. Fuentes. So getting more than 300,000 staff members on 
the same page is going to be difficult, and we understand that, 
you know. But it is unacceptable that veterans continue to 
receive misleading information, or even dated information.
    You know, we do commend VA for recognizing this issue, and 
I have to commend Dr. Tuchschmidt for being very receptive to 
all of our recommendations and being willing to listen to them 
even though he may not like what we are saying. And we have 
been informed that they are in the process of rolling out 
mandatory training for all VHA staff and specialized training 
for scheduling and fee basis staff. And that second part, I 
think, is the most important part. Because the scheduling staff 
and that frontline staff are the ones who are really 
interacting with the veterans, and they are the ones who really 
need to know the intricacies and nuances of the program.
    You know, I don't think they are there yet, but with 
support from the leadership, which they have, I feel that they 
can get there.
    Mr. Abraham. Mr. Butler, do you have a comment?
    Mr. Butler. The key to training is making sure you have 
articulated, defined policies and operational procedures. Those 
are the nucleus and the basis for VA staff to use and to 
educate staff members on the functions and roles of a program.
    Prior to my position at the American Legion, I was the 
deputy director for policy for VA. And so in that area, you 
have to make sure that when Congress enacts a law, VA develops 
regulations, there are supporting policies in place to ensure 
that staff in the field understands the role, the functions, 
and the procedures for any new law that has been enacted. 
Without appropriate policies and procedures, that can lead to 
miscommunication among staff and senior leaders.
    So, one of the important elements, as I stated in my 
testimony, is that VA has not issued any national policies or 
handbooks that define the operational role and procedures of 
the Choice program. And it also hasn't linked those policies 
and--linked anything to any other existing policies and 
procedures. So while you issue fact sheets and press releases, 
that is great. But VA needs to look at what are the guiding 
policies and procedures that they need to provide to field 
staff so that staff can use that information as a guide for 
training their staff.
    Mr. Abraham. Okay. Thank you.
    Mr. Violante, real quickly.
    Mr. Violante. Yes. I would associate myself with the 
comments made by my colleague from VFW, and just add, I think 
one of the biggest problems right now are there too many 
programs out there that have too many criteria that have to be 
met. And I think it should be simplified. I think we have heard 
it from both the first panel and this panel that, you know, 
there should be one program for outside non-VA care, and it 
should be simplified.
    Mr. Abraham. Thank you.
    Mr. Neiweem, real quick.
    Mr. Neiweem. Yes, Mr. Chairman, I will just be more brief.
    First and foremost, the vast majority of VA employees do a 
really great job when they have the right tools. I would 
associate myself with Mr. Butler specifically. A training 
guideline or a memo that can be very brief that could be in 
their office space. If A, here. If B, here, so that every 
single VA scheduler says the same thing getting off the phone, 
and try to create a memo with just that basic information in 
front of them.
    Mr. Abraham. Okay. Thank you. Good answers.
    All right. Mr. O'Rourke.
    Mr. O'Rourke. Thank you very much.
    You know, first I would like to note that Deputy Secretary 
Sloan Gibson is still here with us, and he is listening to your 
testimony right now as the other participants in the last panel 
are, and I think that is important in demonstrating the VA's 
commitment to not just listening and responding to us, but 
listening and responding to you. So I appreciate you being 
here, Mr. Gibson.
    Mr. Fuentes, you, I understand, were working on the Senate 
side during the development of the Choice Act, and so you may 
be able to shed light on a question that I think was raised by 
the chairman of the full committee concerning budgeting. And 
the CBO when they were scoring the Choice Act assumed that 
these funds would be fully consumed bill early fiscal year 
2016. Early fiscal year 2016 could be, you know, anytime in the 
next, you know, 6 to, let's say, 12 months. And yet so far we 
have only obligated $500 million.
    Any light you can shed on the miscalculation there?
    Mr. Fuentes. Yes, sir. I did have the distinct pleasure of 
working for then-Chairman Sanders at the time.
    I think the projections on utilization were over-
calculated. I mean, VA was given 3 months to implement this 
very complex program. We are not surprised that there were many 
issues, to commend VA and TriWest and Health Net, they have 
been really fixing the problems as they go. I think that 
participation definitely needs to improve. The number of 
veterans eligible also needs to be improved, because we know 
that there are certain issues with the standard. I mean, the 
VFW is committed to ensuring that that standard serves the best 
interest of veterans, and we know that it doesn't right now. In 
terms of wait times, veterans are waiting too long.
    Mr. O'Rourke. I am sorry to interrupt you. I just--I wanted 
to--I understand that we are all trying to fix it, I am just 
wondering how the mistake was made in the first place in terms 
of projecting, but it may have to be a question answered at 
another time.
    I want to follow up on another thing that you said, which 
was, the need to look at leasing and sharing facilities with 
other providers in the community.
    Could you expand on that.
    Mr. Fuentes. So you need to have an innovative look at how 
to expand capacity. You know, we have learned from many of VA's 
mistakes that building facilities and large facilities is not 
always the best solution. When Fort Riley, Kansas is building 
facilities, then the local VA should say: Well, you know, what? 
We don't have the capacity to provide, women-specific services. 
DoD, MTFs you have been doing that for quite some time. Can we 
rely on you to meet that need for our veterans?
    Same thing with Indian Health Services in Alaska. They are 
doing a great job of doing that, but in other areas where they 
are present, we can expand on that, but also, sharing 
agreements. Denver was originally supposed to be a shared 
facility with the medical with the school.
    Mr. O'Rourke. Right. And would you expand that to include 
private hospitals?
    Mr. Fuentes. Yes. Better use of affiliated hospitals and 
hospitals across the street as well.
    Mr. O'Rourke. Not just DoD and other public services, but 
private hospitals.
    All right. I think that is important, and I wanted to give 
Mr. Violante a chance to perhaps expand on his comments. I feel 
like you almost presented us with a false choice of privatizing 
or eliminating VHA, or just doing better with the mandate that 
we already have. But I am struck by the fact that we have 
28,000 open positions within the VA, that wait times, despite 
the crisis following Phoenix, or at least the attention to the 
crisis that existed prior to the news about Phoenix, but in 
almost the year since then, wait times have not improved at the 
VA. To me, it is really clear that we owe it to veterans to try 
some things that might be uncomfortable, that may carry some 
risk with them.
    I am not suggesting eliminating the VHA, but wanted to get 
your comments on what the threshold for experimentation might 
be, whether we can try pilot projects, for example, to see if 
we can't work better with private providers in the communities. 
Love for you to respond to that.
    Mr. Violante. And, again, I don't think DAV has a problem 
with using private providers. My concern is where--where the 
report that CVA put out could possibly lead VA. I mean, we 
believe that no veteran should wait too long or travel too far, 
no enrolled veteran in VA healthcare. VA needs to be able to 
address their needs in the community if need be. My only 
concern is that if we are providing--and, again, whether you 
call it Choice or purchased care, you know, ARCH, or PC3, VA 
needs the ability to do that. It is just a matter of how they 
go about doing it and where that choice lies.
    Mr. O'Rourke. Thank you.
    Thank you, Mr. Chairman.
    Mr. Abraham. Well, thank you again, gentlemen, for being 
here and for your patience. It has been some very good 
testimony. The committee may submit more questioning and we 
would ask for your expedience in answering those if so 
submitted.
    If there are no further questions, you are now excused. I 
ask unanimous consent that all members have 5 legislative days 
to revise and extend their remarks and include extraneous 
materials. Without objection so ordered. I would like to, once 
again, thank all of you here.
    This hearing is now adjourned.
    [Whereupon, at 12:40 p.m., the committee was adjourned.]

                                APPENDIX

               Prepared Statement of Chairman Jeff Miller

    Thank you all for joining us for today's oversight hearing, 
``Assessing the Promise and Progress of the Choice Program.''
    We have two full witness panels ahead of us so I will keep my 
opening remarks short in the interest of time.
    The Choice program was created last summer to address an 
unparalleled access to care crisis at the Department of Veterans 
Affairs (VA).
    Six months after it was first implemented, the program has 
successfully linked thousands of veterans with quality healthcare in 
their home communities.
    We can all be proud of that and I applaud VA and the two Choice 
program Third Party Administrators (TPAs)--Health Net Federal Services 
and TriWest Healthcare Alliance--for their initial efforts to quickly 
implement the program and their ongoing efforts to make it work well 
for the veterans who need it.
    That said, the implementation and administration of the Choice 
program has been far from perfect and many veterans are still waiting 
too long and traveling too far to receive the health care they need.
    There are many reasons for this--a lack of outreach to veterans who 
may be eligible, a lack of training for front-line VA and TPA staff, a 
lack of urgency on the part of many VA medical facilities who continue 
to adhere to their old ways of doing business--and I could go on.
    During today's hearing we will discuss how to eliminate impediments 
to greater veteran and provider participation in the Choice program and 
how to ensure VA and TPA staff are properly trained and seamlessly 
coordinated to respond to veteran and non-VA provider questions and 
ensure the timely delivery of care.
    We will also begin discussing where VA goes from here.
    The Choice program is just one of many ways VA provides care 
outside of the Department's walls.
    All too often VA's numerous purchased care programs and authorities 
operate in conflict with one another--using different eligibility 
criteria, different programmatic requirements, and different 
reimbursement rates to achieve the same goal.
    That does not serve VA, American taxpayers, or--most importantly--
veterans and their families.
    As was stated many times last year, business-as-usual is not an 
option.
    Congress has consistently met the Administration's budget requests 
for the Department of Veterans Affairs and, as a result, VA's total 
budget has increased by seventy-three percent [73%] since 2009.
    In comparison, veteran patients have increased by only 32% since 
2009.
    Yet, VA has not and cannot fully meet the needs of the entirety of 
their patient population.
    This illustrates clearly that VA's failures are not a matter of 
money, they are a matter of management.
    There is no one way forward, but there can also be no mistaking 
that, by challenging VA's failing status quo approach to purchased 
care, we find ourselves at a crossroads of opportunity that never 
existed before.
    I am encouraged by and in agreement with the numerous testimonies 
today that emphasize the need to build a coordinated managed care 
system that incorporates VA care along with needed community options 
and resources.
    While working to improve the Choice program today, we must all 
prepare for the Choice program of tomorrow--one that brings the 
universe of non-VA care together under one umbrella so that the care 
our veterans receive is more efficient and effective, regardless of 
where it takes places.
    However, I look forward to working with veterans, VA, veteran 
service organizations, and all other interested stakeholders on this 
effort, beginning with your statements this morning.

          Prepared Statement of Corrine Brown, Ranking Member

    Thank you, Mr. Chairman, for calling this hearing today. As you 
know, it has been about 9 months since the President signed the 
Veterans Access, Choice and Accountability Act into law. This hearing 
is one in a series of hearings designed to follow the progress and 
ability of the VA to provide healthcare to veterans in the twenty-first 
century.
    I am sure we can all agree the VA provides the best healthcare for 
returning veterans in this country. However, we all know that there are 
challenges to this mission and the recognition that VA cannot do it 
all.
    The Choice Program offers eligible veterans access to healthcare 
that they may not have had in the past. One of this Committee's highest 
priorities is to ensure that veterans receive the highest quality 
healthcare in a timely manner and in a safe environment. For those 
veterans who choose to use the Choice Program, I want to make sure that 
this is happening.
    Mr. Chairman, VA has served the special needs of returning veterans 
for 85 years and has expertise in providing services that address their 
unique healthcare needs, including prosthetics, traumatic brain injury, 
Post Traumatic Stress Disorder (PTSD), and a host of other veterans 
specific injuries. My focus continues to be on ensuring that Veterans 
Affairs retains the ultimate responsibility for the healthcare of our 
veterans, regardless of where they choose to live. The VA is the best 
system we have to serve the health care needs of the veterans returning 
from war. We cannot allow circumstances that would render the system 
unable to serve the very veterans it was built to serve.
    The DAV, in its submitted testimony, says ``Although the VA today 
provides comprehensive medical care to more than 6.5 million veterans 
each year, the VA systems' primary mission is to meet the unique, 
specialized health care needs of service-connected disabled veterans. 
To accomplish this mission, VA health care is integrated with a 
clinical research program and academic affiliation with well over 100 
of the world's most prominent schools of health professions to ensure 
veterans have access to the most advanced treatments in the world.'' I 
believe that says it all.
    I look forward to hearing from the Deputy Secretary today and all 
the witnesses to learn how the VA can better treat those veterans who 
have given so much in defending the freedoms we all hold so dear.

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                      Statement of Danny Breeding

    Nice seeing you again this past Monday in Morristown. Per our 
conversation regarding the Veterans Choice Card, all I have heard from 
our local veterans in Hawkins County ``its a joke''. Personally I 
called the toll free number and was told by a lady that the area I 
lived was not ``programmed'' in. I was told to call back in 7-10 days 
to check if information was available. This was in December after the 
October roll out.
    I have also heard from a few veterans that they were told because 
residing in the immediate Rogersville area, we had a VA facility, and 
they could attend there. (after obtaining their own appointment) They 
were referring to our CBOC, which only has a primary care physicians 
are in our OBOC.
    Hearing other disgruntled stories through The Tennessee Department 
of Veterans Affairs quarterly training, I must agree with my fellow 
veterans I serve, the program is a joke indeed. Some common sense 
needed to be implemented before this program was rolled out . . . 
.mainly the miles issue and of course realizing the difference between 
a CBOC and a VA Medical Center.
    Bill, I use the VA Health Care pretty much exclusively, I've only 
good things to say about my treatment. I'm just thankful I haven't had 
to depend on The Choice Card for care. With my Service Connected PTSD, 
I would probably make a fool of myself!
    Regards, and my best to you and Congressman Roe,
    Danny Breeding
    VSO/Hawkins County

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